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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: —Tr Page of Facility Address: City: Inspe tion Dat FA#:2 C O PR#: Prog m Ele ent: �JCe O 2522 �� 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. S Tank (2820) ❑ Containers (2821) #of Containers: TA#: f C/ 1Product Type: 0 I Total Capacity: `� � fl gallons (per tank or cumulative for containers by product type) Install Date: YTank (2820) ❑ Containers (2821) #of Containers: TA#: _- 2 / ^ Product Type: Total Capacity: l� �� gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: -7 7.O 3 Total Capacity: ��O gallons Type: rfl 1 (per tank or cumulative for containers by product type) Install Date: VTank (2820) ❑ Containers (2821) #of Containers: TA#: 12 7 7 / 4 Product Type: 0 1 Total Capacity: gQ gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 7 2,22 5 Total Capacity: Product Type: �TYT.c.✓1 �4 j p y: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 45v gallons Total Capacity for Site: I Lo C5 c) gallons Comments: Aid � . EHD I ctor: Reviewed Date: Entered Date: By Initial: KI G �,��,y,„ (p 1� �V By Initial: Y 1)2 "Abo egro storage tank means a tank that has the capacity to store 55 gallons or more of pe roleum. "Coftairfer means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM