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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: _ Page of Facility Address: ^ City: Inspecti n Tt : FA #: � � � E PR W F(Zo�3D 1�� Prog �m �legngtt►t: 1 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. Sf Tank (2820) O Containers (2821) #of Containers: * TA#- Dmf D� 1 t^ Total Capacity: p y: 2 � Product Type: �Q gallons (per tank or cumulative for containers by product type) Install Date: iTank(2820) ❑ Containers (2821) #of Containers: TA#: �2tu &&o 2 � �l gallons Total Capacity: , Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: Ll6-/ q (& Oo`Z 3 Total Capacity: gallons t, Product Type: (per tank or cumulative for contains s K product type) Install Date: ❑ Tank (2820) - Containers (2821) #of Containers: �_ TA#: 66— g(?0—'5 4Product Total Capacity: ��i 0 gallons Type: / /Z� f� r (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:gallons Total Capacity for Site: gallons Comments: 11-2 Zzr EHD Inspector: r �— Reviewed By Initial: Date: �� ,`�.0 LEnteired tial: Date: r 0 Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum.l "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08