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l h SAN JOAQUIN COUNTY ' Y 73 VIRONMENTAL 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 N me: �l /:-r A di'l'l A-n C-!7' Page of L_ Facility Address: 4 J� /V /v U City: Ins ti 17d, FA#: PR#: Program Element: Tank/Container information Complete for all sites with cumulative aboveground storage of petroleum 2:1,320 gallons in tanks"and containers". Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1Product Type: Total Capacity: -00 gallons – (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820)' ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: � gallons -••-••— (per tank or cumulative for containers by product type) Instal! Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Pr°duct Type: (per tank or cumulative for containers by product type) Install Date: El 'Tank (2820) ElContainers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) In: Date: Total Capacity this Page: Sr gallons Total Capacity for Site: Jr" gallons Comments: EHD Inspector: � Reviewed Date: Entered Date:✓ By Initial: V\AJ ��_Q� By Initial: "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 rnoved when full. EHD 28-01 AST SURVEY FORM 09/12108 ,