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` } SAN JOAQUIN COUNTY ' rVit. 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 Na � J ! Page of Facility Addres City: Inspection Date/ Z FA#: PR#: Program Element: 556 9 N oS - 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. C `Tank (2820) El Containers (2821) #of Containers: TA#: �61$� 1 Product Type: a D e Total Capacity: %c 661'7 gallons (per tank or cumulative for containers by product type) Install Date: li ank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: `�� `� ` gallons (per tank or cumulative for containers by product type) Install Date: 2' Tank (2820) ❑ Containers (2821) #of Containers: TA#: 9 17 7" 3 / Total Capacity: P gallons Product Type: (per tank or cumulative for containers by product type) Install Date: [wank (2820) ElContainers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: Z �� gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ElContainers (2821) #of Containers: TA#: 5Product Type: y Total Capacity: / gallons (per tank or cumulative fog containers by product type) Install Date.- Total ate:Total Capacity this Pa tr gallons Total Capacity for Site: �2 g �d gallons Comments: EHD Inspector: / Reviewed Date: Entered Date: By Initial: U„Aj l{_�g,t)� By Initial: 1-1> l '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