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i SAN JOAQUIN COUNTY . 4� }� ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility NanW.; Page of - P1- 1X GDS � � - o�S Facility Address: City: Inspecti n DAte- 13 FA#: PR#: Program Elem t 95C506-1q3 , 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. ank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: 11gallons Product Type: _V (per tank or cumulative for Fontainers by product type) Install date: lank (2820) ❑ Containers (2821) #of Containers: TA#: 201V gallons Product Type: /7.4 e-4 D Total Capacity: (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ElContainers (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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Instal! Date: - --- Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: s � EHD Inspector: J Reviewed Date: Entered Date: By Initial: Vv C6-0 IJ By Initial: ej2 *Aboveground 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 2$-01 ql' i AST SURVEY FORM 09/12108