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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:vuww.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page of r I7 Tim 4— Facility Address: City: Inspectio Date: �J FA#: / PR#: 67� Pro mEnnt: 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 roduct type. Tank (2820) ❑ Containers (2821) #of Containers: r TA#: 1 � Product Type: Total Capacity: �:. gallons (per tank or cumulative for containers by product type) Install Date: El 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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: �`( � -,gallons Comments: is 42 r�7 i�,� _ 1'( EHD inspector; /�7 Reviewed Date: Entered Date; tom. By Initial: [,!_�tFt, By Initial: D *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. i **Container means a storage device designed to be moved when full. EHD 28-01 AST;SURVEY FORM 09112/08 !