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t 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 Atame: Page_ of 2 Facility Address: v 11 City: Inspection Date: FA#: PR#: Program Element: U3z- 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. M Tank (2820) El Containers (2821) #of Containers: TA#: ,QHS„ 1 Total Capacity: C ProductType: p Y� gallons (per tank or cumulative for contglners by product type) -� Install Date: i Fit Tank (2820) El Containers (2821) #of Containers: TA#:,n 5�/QIR4 2Product Type: Total Capacity: ; gallons (per tank or cumulative for containers'by product type) Install Date: 7A) 2. i ] Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3Product Total Capacity: L-'i gallons Type: � (per tank or cumulative for containers by product type) l Install Date: A) L// Tank (2820) El Containers (2821) #of Containers: TA#: Bu-aD�o�le 4 Total Capacity: G�(j Product Typ o P Y gallons (per tank or cumulative for containers by product type) Install Date: 1 Tank (280) Containers (2821) #of Containers: TA#:/95�119/D �7 5Product Te: Total Capacity: gallons yp '� (per tank or cumulative for co tainers by product type) S Install Date: Total Capacity this Page: -3 ( 2 gallons Total Capacity for Site: 3 l gallons Comments: EHD I s ector: Reviewed Date Entered Date: � V � By Initial: �U� �+ D I51 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 09/12/08 AST SURVEY FORM