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r' SAN JOAQUIN COUNTY t 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: i C/ Page of Facility Address: City: Inspectio Date: ,q Vr c 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. E�,/Tank (2820) ❑ Containers (2821) #of Containers: TA#: r251 g°1 R 1 Total Capacity: �r('� gallons Product Type: (per t nk or cumulative for containers by product type) Install Date: VITank (2820) ❑ Containers (2821) #of Containers: TA#: D,S 1 8955? 27,j—,?rProduct Type: �a e) Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: VTank (2820) ❑ Containers (2821) #of Containers: TA#: h ) g 3 Total Capacity: I r ''' 0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ #of Containers: TA#:Containers (2821) _ 4 z �� Product Type- Total Capacity: -, S gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: 5 � , Product Type: Total Capacity: � gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Pag . � gallons Total Capacity for Site: gallons Comments: D q nl (' � c -R •' 2- 0/llZ,3 4- 2 e"'e EHD Inspector Reviewed ( Date: Entered Date: \�,�I / - By Initial: (6_a l- By Initial: "Aboveground storage tan means a tank that has the capacity to store 55 gallons or more of petroleum. 7 "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08