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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 Na e: rVj /V TCS /?/ S,g''S /N G Page —L- of_(L_ Facility Address: City: Inspection Date, FA#: PR M Progra EI menta /6-3/ es 3�4 S 30 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. Ef/Tank (2820) ❑ Containers (2821) #of Containers: TA#: ,`1 f 1 Product Type: Total Capacity: ® gallons (per tank or cumulative for containers by product type) Install Date: EY, Tank (2820) El Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ElContainers (2821) #of Containers: T #: g'76o3 3 Total Capacity: Z12 op 6 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ElTank (2820) Q"Containers (2821) #of Containers: �_ TA#: 4Product Type: Al'g S%0 Total Capacity: � gallons (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: , ? Y, gallons Total Capacity for Site: gallons Comments: `Tri f EHD Inspector: Reviewed Date: Entered Date: By Initial: --) a-n7- By Initial: cf *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of etroleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08