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L SAN JOAQUIN COUNTY 69 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 Na A aoOto Page of Facility Address: � City: Inspec ion .7 � ate: FA #: PR M Program rzle nt: T 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. 11J�Tank (2820) 11 Containers (2821) *of Containers: TA#: / -/ g (Q9 1 Total Capacity: �r �� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Z��ank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: 0-P2 gallons n Product Type: (per tank or cumulative for containers by product type) Install Date: ank (2820) El Containers (2821) #of Containers: TA#: —/27190 3 Total Capacity: r -t) gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (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: 67 gallons Total Capacity for Site: j— 6-n M Comments: EHD Inspector: Reviewed By Initial: Date: Entered By Initial: Date: -2 "`Aboveground storageAarfk 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