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f; SAN.IOA(aUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax: (209) 468-3433 Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM i Facility ffName: -r(1� Page of Facility Address: City: Insp�,tlo#:7�,�,��, FA M PIT#: Program Eem t: 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 product type. f Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: Total Capacity: �' 3 � gallons (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: S El Tank (2820) ElContainers (2821) #af Containers: TA#: f 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: 6 (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) I nstail Date: Total Capacity this Page: -L gallons Total Capacity for Site: Z-3 -21 gallons Comments: t EHD Inspector: Reviewed Date: Entered Date: / ' By Initial: t� l(`.`a.0 By Initial: �1 j r "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 09112108