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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 Nam ` Page � of Facility Address: City: Inspectio ate• FA #: PIR M Program Element. 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#: 42M 5'r-35 1 Product Type: 2S1� Total Capacity: gallons (per tank or cumulative for con ainers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers:--------. TpA'#: ©, 2 Total Capacity: _ u-0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: PI/Tank (2820) ❑ Containers (2821) #of Containers: TA#: g 3 C Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) U Containers (2821) #of Containers:. TA#: 4 y Total Capacity: r gallons Product Type: (per tank or cumulative for containeri by product type) Install Date: ❑ Tank (2820) E Containers (2821) #of Containers: T #: $ 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: EHD Inspector: Reviewed ` wI Date: By Initial: \1-4v Entered Date: By Initial: Ap * 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