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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: G v ( r -f— Page L of `1-- Facility Address: City: Inspection D te:� o FA #: �`� PR #: Program Element: 7-430 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks` and containers". Com e one box for each tank or each cumulative container product te. ❑ Tank (2820) &ontainers (2821) #of Containers: TA#: $ 1 Total Capacity: gallons Product Type: S (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: 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: j j gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed By Initial: Date: Entered Date: By Initial: HDovegrouna 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