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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: City: Inspection Date: Z l f � !-� jib getT 1/Z �°� /?IFA#: R M Prog&ar7i Itlement: 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. EU Tank (2820) El Containers (2821) #of Containers: TA#: 1 .� Product Type: HiQ/ Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: [II/Tank (2820)(2820) ❑ Containers (2821) #of Containers: TA#: lJ6! 4'�a� 2 ~ Product Type: r Total Capacity: ofd gallons (per tank or cumulative for containers by product type) Install Date: EI/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 ,--- Total Capacity: 5f, gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 0 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: gallons Total Capacity for Site: gallons Comments: (` v 14 EHD Inspector: Reviewed Date: Entered Date: (� By Initial: Q.6.0� By Initial: B "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 09/12/08/08