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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: 1% 0%/ N l Page L of Facility Address: b City: Inspectio Date: 0 FA#: �� R#: Progr�EJ�me (x`00//3 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) ❑ Containers (2821) #of Containers: TA#: /9,S1 g'j�'W 1 Total Capacity: SP-z9 gallons Product Type: _22�.-- (per tank or cumulative for containers by product type) Install Date: /Tank (2820) ElContainers (2821) #of Containers: TA#: 2 Product Type: ��,�` T-7 Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 19 ontainers (2821) #of Containers: _� TA#: qS 9a 3 ter-Jr Product Type: /II/7 ��.� CP L/ Total Capacity: gallons (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: gallons Total Capacity for Site: j j gallons Comments: (,-Ago !al{D//til YA EHD Inspector: � Reviewed Date: Entered Date: By Initial: .�5't� By Initial: *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