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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: City: Inspectio�ate: FA #: PR #: Program E 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. 1 Tank (2820) ❑ Containers (2821) (e Total Capacity: J �� gallons #of Containers: TA#: 19,61 3 Product Type: �AS a r, 7 (per tank or cumulative for containers by product type) Install Date: UV ank (2820) ElContainers (2821) #of Containers: TA#: 2 Total Capacity: _� �� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: D ank (2820) ❑ Containers (2821) *of Containers: TA#: 3�- Total Capacity: 1` _� 6 gallons Product Type: / �(�i3O �— (per tank or cumulative for containers by product type) Install Date: E417/ank (2820) ❑ Containers (2821) #of Containers: TA#:h 4 Total Capacity: 01)e) gallons (per tank or cumulative for containers by product type) Product Type: % Install Date: EZ-- ank (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: gallons Comments: EHD Inspector:Reviewed z ,� /`� Date: By Initial: t ` �,' lG�_ p� Entered Date: By Initial: � o*fe21 "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