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s SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.$)gov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: � Page of Cit Inspect, n Date Facility Address: y' �F712,,° FA#: PR#: Program Element: rto 3_1 Tank/Container Informatlon Complp'i for all sites with cumulative aboveground storage of petroleum x1,320 gallons in tanks* and containers". Com let ne box for each tank or each cumulative container product type. 'Tank (2820) Containers (2821) #of Containers. TA#: Product Type: Total Capacity: C7V gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ElContainers (2821), #of Containers: TA#: { I 4' Total Capacity: gallons Product Type: i (per tank or cumulative for containers by product type) Instal! 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: gallons Total Capacity for site: gallons Comments: i F EHD Inspector: c .TL a Reviewed Date: EnteredDate: By Initial: �,a�-a� By Initial: M *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. I; EHD 28-01 AST SURVEY FORM 09/12!08