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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: T ,lG��' FPR C'� �2/7t Page Z of -2— Facility Address: City: Insstion Date: 2909��. � 1-//o FA#: 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. 1 E� Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1Product Type: Yza� Total Capacity: /5� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ 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: Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: �� gallons Comments: U EHD Inspe r: Reviewed Date: Entered Date: By Initial: By Initial: U "'Above,grourMtorage tank means a tank that has the capacity to store 55 gallons or more bf petroleum "Contal r means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM