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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: �` L )% /V C'/ Fage of Facility Addre : City: Inspection Date: o '3 a C c, f,; -TO C- `�_ 3' FA#: PR#: Program Element: 2 b 28 3( Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks' and containers`*. Complete one box for each tank or each cumulative container product type. 2T_/Tank (2820) ❑ Containers (2821) #of Containers: -TA#� 1Total Capacity:p y: Cr gallons Product Type: rrl(o7 l k' i (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: 4d' Tank (2820) El Containers (2821) 2 Product Type: s fi_51 Total Capacity: l(7 P O gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (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 ate:Total Capacity this Page: f gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: q Entered Date: By Initial: tpz-� 1 I A By Initial O "`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