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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 NameQ FPage of Facility Address: Cit Inspe tion Dat FA#: PR#: Pro ram EI mgnt: ® 570? 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. n'Tank (2820) ❑ Containers (2821) #of Containers: TA#: '72/� 1 Total Capacity: 0 0(9 gallons Type: (per tank or cumulative for containers by product type) Install Date: W lank (2820) ❑ Containers (2821) #of Containers: TA#: d 1_1 9 3 2 Total Capacity: 66 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: VTank (2820) El Containers (2821) #of Containers: TA#: � 3 L Product Type: Total Capacity:Capacity: �cQ--v'�'->'� gallons —La (per tank or cumulative for containers by product type) Install Date: i Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 -' Product Type: �-�, Total Capacity `�- U 0 � gallons 7 (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: h /-7 5 Product Type: 7iL � Total Capacity: L3s-;1'0 gallons (per tank or cumulative for co ainers by product type) Install Date: Total Capacity this Page: �'� (�y1 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: *Aboveground s rage 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