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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: u „� Page of IV /q Facility Address: City: Inspection Date: ✓ 2 C7 FA#: P M Program Element: 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. #of Containers: TA#: B� 9�'/ (p Tank (2820) El Containers (2821) v 1 r C, dA Product Type: z2, Total Capacity: � gallons (per tank or cumulative for containers by product type) Install Date: j Lfank (2820) El (2821) #of Containers: TA#: ��1 2 -�• �? Product Type: Total Capacity: 5 > 7 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: ,i aqi 1 g 3 �� Product Type: C- �f; Total Capacity: � gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: El Tank (2820) containers (2821) _ TA#: I �� 4 Product Type: /'�-0 f C��' J Total Capacity: '2-" gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 2"bontainers (2821) #of Containers: TA#: /9,Q g2O 5 Total Capacity: �� e>-c> gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 1 ' L-41) gallons Total Capacity for Site: gallons Comments: EHD Inspector Reviewed Date: Entered Date: y By Initial: t� By Initial: '"Aboveground storage tank means a tank that has the capacity to store 55 gallons or more o petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08