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� SAN JOAQUIN COUNTY ,Wow) HEALTH DEPARTMENT Tr " 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209)468-3433'Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: f . 1 A � PAUL Page of Facility Address: ' y: Inspection Dat EL�i FA#: PR#: Y Program le nt: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2:1,320 gallons in tanks* and containers". Com lets one box fdr each tank or each cumulative container roduct type. Tank (2820) ElContainers (2821) #of Containers: n_ TA#: 1 Total Capacity: p gallons Product Type: n _ om_ (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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: i ❑ 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) ElContainers (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: O 0- gallons Total Capacity for Site: gallons Comments: EFID Inspector: Reviewed Date: Entered Date: By Initial: 15 By 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 moved when full. EMD 28-01 AST SURVEY FORM 09/12/08 ��