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SAN aJOAQUIN 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: 14 Page of i. Facility Address: ^ City: Inspection Date: / j, -r-� C � ,CZ- _4 h FA#: PR#: Program Element: 12 �0 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 co ainer product type. El Tank (2820) Containers (2821) #of Containers: TA#: �� 1 Total Capacity: // 0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date.- El ate:❑ 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: gallons Total Capacity for Site, gallons Comments: EHD Inspector: � Reviewed Date: Entered Date: �� By Initial: By Initial: ?f Z Q `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 09/12/08 AST SURVEY FORM