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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: _ _ A Page L of Facility Address: City ! j I nspecti ory Date: FA #:PR #: �3J D��QQ70 - Program Elemen 2- 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. Tank (2820) ElContainers (2821) #of Containers: TA#: rS 1 Total Capacity: ,3� gallons Product Type: az-2�22 (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: ��`Tc3 2 Total Capacity: 3 bV gallons Product Type: ✓I//q S l �i ( c (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) MContainers (2821) #of Containers: TA#: �c5-1 `�� D 3 � Product Type: Total Capacity: .�� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) I /Containers (2821) #of Containers: % TA#: 4 �- Total Capacity: � ,� gallons Product Type: r''�J %� 1� j�Z (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: r7l 0 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date:Entered Date: By Initial: By Initial:4991 *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 09/19/08