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" X d 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: QA A S Page of j Facility Address: City: Inspe t an Da I Z. Pivr^ AV`s 6 b FA#: PR M Progra Elem nt: /217", Z if ti 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 Rroduct type. EDI/Tank (2820) ElContainers (2821) #of Containers: TA#: 1 - Product Type: . Total Capacity: z gallons -- �-- (per tank or cumulative for con ainers by product type) Install Date: �,. - / Tank (2820) 0"Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: 14 24,1 , ©,r tJ (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: _ Total Capacity: gallons •••• (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: 4 EHD Inspector: Reviewed 1 Date: Entered Date: By Initial: 1 -1,�,�91 By Initial: _ l 3 :*Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of p roleum- **Container means a storage device designed to be moved when full. � EHD 28-01 AST SURVEY FORM 09112/08