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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: G Pae of Facility Address: City: Inspecoon Date: /06 FAR#: ProgramEle7ent: P a 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. ElTank (2820) L 11etontainers (2821) #of Containers: _� TA#: 1 Product 0 Total Capacity: C rO gallons yp (per tank or cumulative for conta nl ers by product type) Install Date: ElTank (2820) nontainers (2821) #of Containers: �^ TA#: 2 ( Product Type: �✓ �� /� m /I,/ Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Tank o(2820) ❑ Containers (2821) #of Containers: TA#: d $$ 3 Total Capacity: r�C9 gallons Product Type: /9 S (per tank or cumulative for containers by product type) Install Date: �ank (2820) El Containers (2821) #of Containers: TA#: B 5 1 W I?V 4 Product Type: Total Capacity: 0 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: 3 O gallons Comments: EHD Inspector: Reviewed Date: Entered Date: 1 By Initial: VA 2n By Initial: O "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