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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT t 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: 6 Page � of Facility Addres : City: Inspection pate: /� FA#: PR#: Program EI ent: 17 o 2 S a X11 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. 2"Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1r' Product Type: LZ 4 ✓ i 4: Total Capacity: r gallons (per tank or cumulative for Containers by product type) Install Date: ©/ank (2820) ❑ Containers (2821) #of Containers: TA#: D ro- 2 Total Capacity: ?G c> J gallons Product T. _ (l �� (per tank or cumulative for containers by product type) Install Date: ElTank (2820) al/containers (2821) #of Containers: Z TA#: a517 q� 3 Total Capacity: 4-0 0 gallons Product Type: 1.7 o :7-C, YC, D % (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: :TA#: 06-1`7 4 Total Capacity: 10a 1) gallons Product Type:! (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ #of Containers: TA#:Containers (2821) 5 Product Type: n^.3- Wl l Total Capacity: /� />/J gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: el gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed �\ Date: Entered Date: By Initial: VAS By Initial: w '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