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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: Page -' of Facility Address: ty: 5. A / / Inspection 77t? - FA #: PR #: ProgramElement: 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. 173 -Tank (2820) ❑ #of Containers: TXi- Containers (2821) 1 , to Product Type: Total Capacity: - �' '� " "gallons (per tank or cumulative for con ainers by product type) Install Date: Tank(2820) ElContainers (2821) #of Containers: TA#: 2Product Total Capacity: 0P gallons 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 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: 7 �¢,C� L� gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: By907-6--- Initial: Entered r Dat �/ 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 09/1?ros