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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: /D/_" ^✓%� 1 A/r r / Page of Facility Address: _ City: Inspectio Da FA#: PR#: Program Element: S4 Z Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >tl,320 gallons in tanks` and containers". Com fete one box for each tank or each cumulative container product type, [:` ank (2820) Containers (2821) #of Containers: I TA#: 1 -3Product Type: z Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) C(Containers (2821) 11 #of Containers: �_ TA#: if 1 2Product Type: Total Capacity: 2-- J—O gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑'Containers (2821) #of Containers: TA#: 3 _-1 Product Type: Total Capacity: y 1 0) gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ElContainers (2821) #of Containers: TA#: 4 � Product Type: Total Capacity: c7 t� o c/ gallons � (per tank or cumulative fof containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: _12? b 5 � Product Type: Total Capacity: ;" -0 .y gallons r T� (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: ?' S (�� gallons Total Capacity for Site: O gallons Comments: EHD Inspector: Reviewed �UA Date: Entered Date: By Initial: lJw` 1� By Initial: / 'Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. l "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08