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SAN JOAQUIN COUNTY L.41RONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: /j /'livV 1A-'6' / uvf [� ' 1 t�/� C -( Page of , Facility Address: Inspection Date: FA M PR M Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. Tank 2820 #of Containers: TA#: Tank(2820) ❑Containers (2821) 1 ^� Product Type: (��Q� 0-7 l � _ Total Capacity: J C)gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: �- TA#: 2Product Type: j,�S-P� � /' 0� Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 'j ! gallons Total Capacity for Site: gallons Comments: 01-7 EHD Inspector: _ Reviewed Date: By Initial: 1 b I ) Entered Date: By Initial: *Abo gro d storage tank mean`s a tank that has the capacity to store 55 gallons or more of petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 REV 04/19/12 AST SURVEY FORM