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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: /� / , % ,j Page ! of Facility Address: `, City: Inspection Date: FA#: PR#: Program Element: P502 711-0 r 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. 0 Tank (2820) ❑ Containers (2821) #of Containers: TA#: B j !ZT7 2 1 Total Capacity: t) gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 2_ ank (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) El Containers (2821) #of Containers: TA#: 3 Total Capacity: Lo r_-;7z:9 Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 gallons Product Type: Z!j-4 L^=/JT Total Capacity: Z� g (per tank or cumulative for containers by product type) Install Date: ED/Tank (2820) ❑ Containers (2821) #of Containers: STA#: 5 Product Type: /f-T f--" Total Capacity: A Z--O gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Pp- '� � `� _ gallons Total Capacity for Site: j gallons Comments, 1 '�1 J 111 2 �a EHD Inspector: �f % Reviewed Date: Entered Date: By Initial: y �, �l�r(�� By Initial: �j, 3� *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 09/12/08