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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 Named n �"1 "" �- 1 5 Page 2-- of Z- Facility Address: I City':o Inspecti Dat FA#: D PR#: Program Ele nt: 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) Containers (2821) #of Containers: _ TA#: 1 Total Capacity: 65— gallons Product Type: S> I,C)U lq-0 APIA r (per tank or cumulative for containers by product type) Install Date: El Tank (2820) Containers (2821) #of Containers: TA#: 2 Total Capacity: � gallons Product Type: p y: (per tank or cumulative for containers by product type) Install Date: TA#: 3 Product Type: ` Total Capacity: "n gallons r—. �p,y� 1 — (per tank or cumulative for containers by product type) t 115{ 01' �j�I �Yj(/t 1 ' yNQ��i(-e'c . Wj'P C Install Date: "� 1 ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: 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 Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date. Entered Date: By Initial: By Initial: "Aboveground stor ge 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 09/12/08 AST SURVEY FORM