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i 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: Inspe9tion Date: FA#: PR#: Program lement. 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. EDI/Tank (2820) ElContainers (2821) #of Containers: ` TA,#: 1 Product Type: L � t Total Capacity: j ,. - r, gallons (per tank or cumulative for containers by product type) Install Date: /Tank (2820) ❑ Containers (2821) #of Containers: TA#: C2 h 17 262- 2 Total Capacity: / (? � gallons Product Type: (per tank or cumulativef ro containers by product type) Install Date: iTank (2820) ❑ Containers (2821) #of Containers: STA,,#: 6671 _)'j6' 5_!'7 3 Product Type: 1 4-12 Total Capacity: � n' gallons ° (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 713 L., D 4 r Product Type: �K 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 ate:Total Capacity this Page: -3 gallons Total Capacity for Site: 3 0-0 gallons Comments: EHD Inspector Reviewed Date: Entered Date: �'� By Initial: V4 Oq 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