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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.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: ^^ Page -- of Facility Address: / % City: �� Inspection D te: ! �i i �7 0 FA #: PR #: Program lerrerl„ 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#: 67) c?, /p 1 F �_ Total Capacity: � ' gallons Product Type: (per tank or cumulative for containers by product type) Install Date: !Tank (2820) ❑Containers (2821) #of Containers: TAS#:� / / 7 2 Total Capacity: � 0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 13 -Containers; (2821) #of Containers: TA#: Cr 3 1 g 3 Total Capacity: / / gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El Tank(2820) 0 Containers (2821) #of Containers: �- TA#: —J- 4 Total Capacity: , �/ gallons Product Type: /l7 �� i C>Y�� 01- 4— (per tank or cumulative for containers by product type) Install Date: ElTank (2820) Containers (2821) #of Containers: TA#: (� 5 Total Capacity: � p y J gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: U; gallons Total Capacity for Site: gallons Comments: EHD Inspector: / Reviewed By Initial: Date: Entered , Date: By Initial: 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!12/08/08