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40 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: r (f l;' S"r Page ` of Facility Address: V City: Inspectio Dated FA#: PR#: Program Element: 21PRo �3oi� �g 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. C Tank (2820) ElContainers (2821) #of Containers: TA#: 1 Total Capacity: gallons Product Type: � a�Z (per tank or cumulative for contfiinbrs by product type) Install Date: L1i'ank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: -kp Total Capacity: o t, �, gallons (per tank or cumulative for containers by pro e) Install Date: BJ/ Tank (2820) ❑ #of Containers: TA#:Containers (2821) --�- 3 Product Type: QL- Total Capacity: ® � gallons (per tank or cumulative for containers by product type) Install Date: z Y s ❑ 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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: `Z gallons Total Capacity for Site: j gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: /1,1�� By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleu . "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08