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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 Facilit Na y i:e4oi6tl��- Page of Facility Address City: –I— Inspection Date: FA #: PR #: Program Element: " o5 ,7)Z 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. f/ Tank (2820) ❑ Containers (2821) #of Containers: t TA#:� q'� 1 Total Capacity: � � U gallons Product Type: w' (per tank or cumulative for containers by product type) Install Date: G,,,Tank(2820). ElContainers (2821) #of Containers: TA( #: �s 2Total Capacity:� ((� gallons . Product Type: 6aV'�un1Zt7 a (per tank or cumulative for containers by product type) Install Date: " El Tank (2820) [Containers (2821) #of Containers: ' TA#: �%/ 3 Total Capacity: 5< gallons Product Type: �� I (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: IL6—/ L � '2/�_ 4 Total Capacity: S� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 19Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 ' Total Capacity: gallons Product Type: Ot (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: 8 7'�U - gallons Comments: EHD Inspector: Reviewed Date: Entered Date: ` By Initial: By Initial: ID I - 0 --HDovegrouno 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 09/12/08 AST SURVEY FORM