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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: Inspectio `D�t FA#: PR#: Program E ment: yv 191 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. Ei/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 0,x 1 '7 1?/y 1 Total Capacity: l gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 10 JTank (2820) ❑ Containers (2821) #of Containers: TA#: o •- 2 Total Capacity: C? �� _gallons Product Type: (per tank or cumulative for containers by product type) Install Date: f r #of Containers: T : 194-1 1 Co 'Tank (2820) El Containers (2821) ---�; 3Product Type: Total Capacity: / C�> gallons (per tank or cumulative for containers by product type) Install Date: [Tank (2820) El Containers (2821) #of Containers: 'FA /�,�/`Z 9 1 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ElContainers (2821) #of Containers: T #: 1651 `Z 2rZ l 0 5 Total Capacity: / r o 0 0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: j gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: � By Initial: 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 AST SURVEY FORM 09/12/08