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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 Farili4v Al�mu• (S f}) s �� e Page of `� Facility Address: City:Inspection Da e: PR #' 0� 2Z SU-5- USTank/Container Program Element: Tank/ContainerInformation 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: _L�Z2 1 Total Capacity: `J, GC C' p Y� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: / (� Tank (2820) ❑ Containers (2821) #of Containers: TA#: -,* J 03q2 2 Total Capacity: �, �C�O gallons Product Type: 2)1'e -se (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3lac— Total Capacity: -%, q �/ � gallons Product Type (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: -7 / 3 gallons Product Type: 651 1 11)" - (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: /V, a � 5 Total Capacity: gallons Product Type:' (per tank or cumulative for containers by product type) 17 ct Install Date: Total Capacity this Page: i I �' �^ gallons Total Capacity for Site:gallons Comments: EHD Ins otor: Reviewed Dater, 11 By Initial: CU r� 1 Entered Date: By Initial: r vvayiu rxa storage tanK means a tank that has the capacity to store 55 gallons or more of petroleum. "Contai4er means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM