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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 Paae 1 nf 'V—o .a�� -- d LaiiR uidt nds the capacity to store 55 gallons or more of petroleum. **Container means a sto evice designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM Facility Address: City: o� Inspection te: FA #: 3 291 PR #: Progra Element: 2931 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: TA#: —2p 1 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) ✓1 Install Date: �t'C" �/C� ___ `t' ' f1 / f �--(J I KTank(2820) ElContainers (2821) #of Containers: TA#: 2Product Total Capacity: 0 C gallons Type: Pf (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: ❑ 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) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: p y: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 5 5tJ gallonsTotal Capacity for Site: gallons Comments: EHD I4ectorZ�.]�,Revievved By Initial Date: I �En Entered , Initial: Dater 'V—o .a�� -- d LaiiR uidt nds the capacity to store 55 gallons or more of petroleum. **Container means a sto evice designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM