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SAN JOAQUtN'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: r� S /c"X�� Ur Page of Facility Address: City: Inspect/on Dat �. T_r5 Ura LF L a D) I� �o FA#: PR#:,[� 7�7Program 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, i Tank (2820) ❑ Containers (2821) #of Containers: T�A##J: 1 Total Capacity: Z/ 0-gallons Product Type: .itPC-rJ (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (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: El Tank (2820) ElContainers (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: EHD Inspector: RevieweduDate: / Entered Date: By Initial: V,"' By Initial: l! A *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. C/ "Container means a storage device designed to be moved4hen full. EHD 28-01 AST SURVEY FORM 09/12!08 I