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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:al t S 0 Page of Facility Address: City: Inspect' n D te: Co 7-?' ,A /4,-� a� FA#: PR M Progr a ent: 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. a ank (2820) El Containers (2821) #of Containers: TA#: cSD 1 Product Type: Total Capacity: gallons (per tank or cu ulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: 2 Product Type: �� Total Capacity: 10-e gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) D'Containers (2821) #of Containers: �_ TA#: o-6-!erq� c';z 3 Product Type: �/U EL/,L Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: / TA#: 4 �✓ Product Type: �VA L�� J1 Total Capacity: 7 gallons (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: - gallons Total Capacity for Site: Z-r gallons Comments: EHD Inspector Reviewed Date: Entered Date: By Initial: By Initial: 00 *Aboveground stor tank means a tank that has the capacity to store 55 gallons or more of petroleum. **Container mean a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08