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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 Ad rens: b City: Inspectio Dto FA #: PR #: �i�o 530 I"7q PrograinI V. 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. X/ C�Tank (2820) ❑ Containers (2821) #of Containers: TA#: ��h ! �,5'?Q' 1 5'D Total Capacity: gallons Product Type: 11!�:x5 (per tank or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: D 2 Total Capacity: � �rr1U gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: JA#: /961 $5`t3 J 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) L1 Containers (2821) #of Containers: T^A#: ' 137 Q_ 4Product Total Capacity: �C)0 gallons Type: S /> (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: 7 gallons Comments: EHD Inspector: Reviewed Date: By Initial: VA /)-I_0� 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