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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: a o r s Page L_ of Facility Address: City: Inspection ate: /1l0W TI TIv yw FA#: PR M Program Elemea+•• — 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: A#: _DPI 8q rjlQ 1 Product Type: Total Capacity: (Le gallons (per tank or cumulative for containers by product type) Install Date: al/Tank (2820) ❑ Containers (2821) #of Containers: -F TA#: 2 Product Type: L?x1 W Total Capacity: 0 gallons (per tank or cumulative for con iners 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 Total Capacity: gallons Product Type: (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 Pag / r,� J?0 gallons Total Capacity for Sit( gallons Comments: EHD Inspector: Reviewed \ Date: Entered Dat�/� By Initial: `, J .l'>, 0 By Initial: 0 *Aboveground storage 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 AST SURVEY FORM 09/12108