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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: ��r � �� page '<:– of � Facility Address: CPlou Inspection Date- C) FA#: PR#.'J-- Program Element: " ;":�2 Tank/Container Info mation 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. ❑ Tank (2820) EY16ntainers (2821) #of Containers: TA#: 04�-/�� $ 1 Product Type: Total Capacity: gallons -� (per tank or cumulative for cont ers product type) Install Date: r—fank (2820) 2 Containers (2821) #of Containers: TA#: 2 Product Type: l//A Total Capacity: � �� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (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 Total Capacity: Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: / gallonsTTotal Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: 3g 4Le `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 09/19/08