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SAN JOAQUIN COUNTY ! tNVIRONMENTAL HEALTH DEPARTMENT ' 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Al 0 FFG U C C t L Page of Facility Address: City: Inspect' n Date: /P FA #: PR M Program Element: o 7 1 -z-,v 7 a 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) ElContainers (2821) #of Containers: TA#: 1 Total Capacity: J C� gallons Product Type: % (per tank or cumulative for containers by product type) Install Date: LYTank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: .; !..9� gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: D 3 Product Type: •S Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: B ❑ Tank 9,Containers (2820) (2821) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: D/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: (¢ Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: d J�J gallons Total Capacity for Site: Pi Jgallons Comments: /V 7//1-)�,y fir- L VGCJ�i Ly EHD Inspector: Reviewed Date: By Initial: a� _By Entered Date Initial: D *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 28-01 AST SURVEY FORM 09/12/08