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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 Facility Name: / Page of Facility Address: �j / ,, / City: Inspectio Date: -70 FA #: PR M Program Element: 3 3 �0-g Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum al,320 gallons in tanks` and containers". Complete one box for each tank or each cumulative container product type. eTank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: 19-0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 01"Tank (2820) ❑Containers (2821) #of Containers: TA#: 2 �� Total Capacity: ,J ( gallons Product Type: (per tank or cumulative for containers by product type) Install Date: '" Tank (2820) ❑ Containers (2821) #of Containers: TA#: /9,� 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: T194 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ontainers (2821) #of Containers: TA#: �1'6 / ! Y'R Z 5 Total Capacity: �.� gallons Product Type: /i r,L2 0'/' (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 2 0 S gallons Total Capacity for Site: `L gallons Comments: EHD Inspector: Reviewed Date: 1� By Initial: Entered Date: By Initial: 1 O "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more 6f petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08