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r* � � - SAN JOAQUIN COUNTY YNVIRONMENTAL HEALTH DEPARTMENT 3 600 East Main Street, Stockton, CA 95202-3029 r Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name. Page of if Facility Address: City: Inspects nat� r 01 Z ti v pD / FA M / f PR#: Program EI e J C7 6 �f B Tank/Container Information. Complete for all sites with,cumulative aboveground storage of petroleum x,1,320 gallons in tanks*and containers". Complete one box for each tank or each cumulative container product type. C�/Tank (2820) ❑ Containers (2821) #of Containers: TA#: a 1 Total Capacity: ,SAV gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) .#of Containers: TAM 2 Product Type: Total Capacity: gallons " (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (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) 11Containers (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: gallons Total Capacity for Site: rig gallons Comments: 1 EHD Inspector: Reviewed . _y Date: Entered Date: By Initial: Com' }t' By Initial: "Aboveground storage tank means a tank th'atihas the capacity to store 55 gallons or more of petroleum. "Container means a storage device designed to be moved when full. EFID 28-01 AST SURVEY FORM 09/12/08 r a 1