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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.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Nam ' N C . IaN Page of Facility Address: City: Inspectio Dat n 1-3g r LS L 1f ,y FA#: PR M Progra Element- Z Tank/Container Information Complete-for all sites with cumulative aboveground storage ofipetroleum X1,320 gallons in tanks" and containers". Complete one box for each tank or each cumulative container Rroduct type. #of Containers: TA#: r + Tank 2820 ❑ Containers 2821 1 _ C� gallons Product Type: ZAag Total Capacity: (per tank or cumulative for containers by product type) Install Date: ElTank (2820) 13Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: I ❑ Tank (2820) ElContainers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ElTank (2820) El-Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ElContainers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Data: Total Capacity this Page: gallons Total Capacity for Site: 50 ID gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: 1! b 5 By Initial: "`Aboveground storage tank means a tank that has the capacity to store 55 gallons or more bf pbtroleum. "Container means a storage device designed to be moved when full. EHO 26-01 AST SURVEY FORM 09/12/08