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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 FacilityNa e: I Page of Facility Address: Cit zInspection Date: ' d � Co�trs�c ,tc.�� G FA M PR M C Program Element: d 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: TA#: 1 Product Type: �, Total Capacity: t�cD _gallons yp ' --:J� `� (per tank or cumulative for containers by product type) Install Date: gr-Tank (2820) ElContainers (2821) #of Containers: TA#: 2 (, Total Capacity: 5 <s� gallons Product Type: 6--et << (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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: I gallons Total Capacity for Site: gallons Comments: EHD Ins a tor: Reviewed Date: Date By Initial: 1LE—ntere—d y Initial: "Aboveground storage tank means a tank that has the capacity to store 55 gallons or mor of petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM