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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: �%) �� r Page Z-- of Facility Address: i �l City: Inspecll�on Date: 15 USC-' �- �� FA PR M Program Elem nt: 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. P—tank (2820) 1:1Containers (2821) #of Containers: c TA#: q' f 1 Product Type: Total Capacity: % > � gallons (per tank or cumulative for containers by product type) Install Date: E?' ank (2820) ElContainers (2821) #of Containers: t,TA#: 19 6 2 ] � � Product Type: Total Capacity: ,f/�� C C gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TQ 3 � Product Type: Total Capacity: ?) gallons (per tank or cumulative for co tainers 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: 2 01_ (4 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: C ' By Initial 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?/08