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SAN JOAQUIN COUNTY NVIRONMENTAL 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 v S -I— Facility Address: City: Inspectio Date: FA#: h ! PR#:D��-! -!'y�DDjj Progra�Elemn J7 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. Eg- ank (2820) ElContainers (2821) #of Containers: TA#: 1 Total Capacity: 5gallons Product Type: �C-t?a2� (per tank or cumulative for containers by product type) Install Date: 1-iank (2820) El Containers (2821) *of Containers: TA#: ��%u� 2 Product l�tie Total Capacity: _ � gallons Type: Q (per tank or cumulative for containers by product type) Install Date: [ I Tank (2820) ElContainers (2821) #of Containers: TA#: 3 Total Capacity:_ gallons Product Type: (per tank or cumulative for containers by product type) Install Date: LYTank (2820) ❑Containers (2821) #of Containers: TA#: 4 �-- �� Product Type: ,�/l= , Total Capacity: 0 gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) 0 Containers (2821) #of Containers: TA#: �; j Q 3 7 5 r,19 Total Capacity: acit : 9 allons Product Type: P5d S 7 �s � (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Z S`- gallons Total Capacity for Site: �j�gallons Comments: EHD Inspector: Reviewed�1 Date: By Initial: Wo !�•«-00t 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