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SAN JOAQUIN COUNTY y 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: 6/i7/G4? Page of Facility Address: City: Inspection pate: j FA#: PR#: Program Element: 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 container product type. L1-'fank (2820) ❑ Containers (2821) #of Containers: _ 'A 1 Total Capacity: j Ct (7 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 7�4ank (2820) ElContainers (2821) #of Containers: TA#: DVI R�a3 2 �� Product Type: �7 Total Capacity: � gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: STA#: _ 3 Total Capacity: gallons Product Type: (per tank or cumulative fo -containers by product type) Install Date: �� r-7 El Tank (2820) 2 Containers (2821) #of Containers: _ TA#: — 4 Total Capacity: gallons Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) _ —ontainers (2821) #of Containers: TA#: 5 Total Capacity: _ gallons Product Typi (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: O 0 gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: cd,��. By Initial: A JC *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