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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page of Facility Address:: City: 14 InspR ' Date• /� FA #: PR #: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks` and containers". Com fete one box for each tank or each cumulative container product type. ❑ Tank (2820) 2 Containers (2821) #of Containers: TA#: 95-/ 2� Z3 1Product 2-� Type: /� c9 Oj'✓ 0/ Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: 0 Tank (2820) ElContainers (2821) #of Containers: TA#: ,— 2r IR r 2 �^Product Type: - / �) 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 Total Capacity: _ gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 12 gallons Total Capacity for Site: gallons Comments: EHD Inspector: N Reviewed Date: By Initial: Entered Date: By Initial: k Aboveground storage tank means 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 AST SURVEY FORM 09/12/08