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SAN JOAQUIN COUNTY . ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Ci Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE'PROGRAM SURVEY FORM Facility Name: a [S o � l � Page [ of Facility Address: T, City: inspection Mte: a0 PR#: Program I me t: ' Tank/Container Information Complete for'all sites with cumulative aboveground storage of petroleum a1,320 gallons in tanks* and containers". it Complete one box for each tank or each cumulative container product ty2e. Tank 2820 F-1Containers2821 #of Containers: TA#: 1 Total Capacity: 2,/0 gallons Product Type:' (per tank or cumulative for containers by product type) Install Date: i Elank (2820) ElContainers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: I' e , ❑ Tank (2820)' ElContainers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (2821) #of,Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El Tank (2820) El Containers (2821) #of Containers: TA#: 5' _ Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: t; Total Capacity this Page: �r� gallons Total Capacity for Site: gallons Comments: �F k 5i EHD Inspector: i /J Reviewed Date: Entered Date: Q� By Initial: By Initial: , 8 *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. r: EHD 28.01 i3 AST SURVEY FORM i 09/12108 t+ i