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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: FA #:PR #: �7� R2 c, Program Element: 1?" g 7 �- 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. ❑ Tank (2820) *Containers (2821) #of Containers: I TA#:6--/ l Ze:� 1 Capacity: "�� gallons Product Type: /4T -F' (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 9�5-19 %zl-z/ 2 Total Capacity: sl`�() gallons Product Type: _M4`6- ":Ii;/ (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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: �/� gallons Comments: up EHD Inspector:Reviewed Date: Entered A/By Initial: =Date:� By Initial: --"Ivunu awiage Lann means a tanK that has the capacity to store 55 gallons or more of petroleum. ` r **Container means a storage device designed to be moved when full. EHD 28-01 D9/12/08 AST SURVEY FORM