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SAN JOAQUIN COUNTY a 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 -IL Page of Facility Address: Cjty:, Inspectio Date, FA#: PR M Prograr6 drneint, . Tank/Container Information Complete for all sites with umulative aboveground storage of petroleum x1,320 gallons in tanks'and containers". Complete one box for each tank or each cumulative container Eroduct type. C3/Xank (2820) ❑ Containers (2821) #of Containers: TA#: a 1 Total Capacity: 4 {9 gallons Product Type: F (per tank or cumulative for containers byproduct 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 Total Capacity: gallons Product Type:ii (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 byproduct type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: Total Capacity: gallons Product Type: (per tank or cumuietive for containers by product type) Install Date: Total Capacity this Page: �j v gallons Total Capacity for Site: �� gallons Comments: JI/O I Q EHD Inspector: Reviewed Date: Entered Date: a By initial: } Cj fLD- , _ By Initial: � & "Aboveground storage fank 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-U1 09!12/08 AST SURVEY FORM } „ Y