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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 Name: 0= Page of Facility Ad ress: City: Inspection ate: FA#: / FOR#: Prog a lem nt- h D IQDt53D X14 D 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#: 1 gallons Product Type: Total Capacity: (per tank or cumulative for c ntainers by product type) Install Date: 59,/Tank (2820) ElContainers (2821) #of Containers: TA#: 2 Total Capacity: "r Q o gallons Product Type: (per tank of 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 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: T gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed , _ _r Date: Entered Date: 8y Initial: ll�^� 'r,�. By Initial: j2 O *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 26-01 AST SURVEY FORM 09/12/08