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c ' 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: U : No F- !a age - of Facility Address: City: Inspection Date: Q Z 1, r �I`/Z, O FAf f PR All: 19 Program Element- / 17 lementl '7 . /6 1 e a 2- 8312 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. EP-lank (2820) ❑ nContainers (2821) #of Containers: TA#: O 1 Product Type: �I�,� / Total Capacity: Std gallons (per tank or cumulative for containers by product type) Install Date: Ed Tank (2820) El Containers (2821) #of Containers: TA#: 6�( $027 / 2 Product Type: Total Capacity: .S (� gallons (per tank or cumulative for containers by product type) Install Date: 2 ank (2820) ❑ Containers (2821) #of Containers: TA#: /9y'2! a7� 3 Product Type: e,�4 c Total Capacity: 2" 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 Capacity this Page:/L� 0 0 gallons Total Capacity for Site: 0 0 gallons Comments: EHD Inspector: Reviewed Date: p� Entered Date: By Initial: By Initial: t� "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