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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 7 --Df Facility Address: /rCity/:,r: Inspect yJate: A FA #: 23 S PR M Program Eler�iQnt: 91 Oma(47 77- Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2_1,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. El Tank(2820) eContainers (2821) #of Containers: TA#: 1 c-- 1-' Total Capacity: ,% _> gallons Product Type: (41A (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (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: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install 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: FF �4 EHD Inspector: Reviewed Date:Entered By Initial: Date: By 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 nsil ?rota