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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: _ /�'•�'��/� S�GDJ ll 'r�u � Page of Facility Address: r ,Gi � Inspection.Date- r ? FA#: PR#: Progra Element: / e �3D14' � _2,330 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container product type, Tank (2820) 11Containers (2821) #of Containers: 1 Total y: gallons Capacity: Product Type: �1C� p (per tank or cumulative for cont iners by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: 2 Total Capacity: '�� gallons Product Type: �lQ 5 I L �L (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: / 0 Z C7 0 gallons Total Capacity for Site: gallons Comments: EHD Inspector: /n Reviewed Date: Entered Date: / cz By Initial: By Initial: 7 *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 nsi1 9/op