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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: W.�75 �� .-�; r� �1'l'��%.� Page_of_ Facility Address: city: Insp tion Date: FA#: PR#: Pro ram Element: 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, ❑ Tank (2820) Containers (2821) #of Containers: � Product Type: it J A LUQ Total Capacity: — gallons �7 (per tank or cumulative for contamers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: Product Type: p y: 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: Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: o gallons Total Capacity for Site: n �j�-�� gallons Comments: EHD Inspector: ( Reviewedf Date: --FEntered Date: t,)�) Kj �(,/� By Initial: o�v '"?,� 5-�� By Initial: *Abovdground 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. EHD 28-01 09/12/08 AST SURVEY FORM