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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 racimy name: o + ` IS Page --of Facility Address: l�� City: Inspec'on FA #: PR M Program Element: 232 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#: �gl� 1 Total Capacity: gallons Product Type: e: (3�- ZDAO yp (per tank or cumulative for containers by product type) Install Date: 2 ❑ Tank (2820) ❑ Containers (2821) #of Containers: I TA#: q /Q 1 Total Capacity: 60 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Containers: � ❑ Tank (2820) ❑ Containers (21%),,.4 3 Total Capacity: 2—a-tj �` uct Type: C (per tank or c%umulative for co ie y product type) Install Date: ❑ Tank (2820) ❑ Containers (M)) #qf Containers: TA ' Total Capacity: Odd uct Type: IeS& (per tank or cumulative for con product type) Install Date: V t� ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: � gallons Product Type: 8� e&& (per to k r cumulat, ft nainers by prodyct type) Install Date: ut• S Total Capacity this Page: �� r�Iv gallons Total Capacity for Site: ` �� illons Comments: t (� EHD Inspector: Reviewed By Initial: * Date: Entered DatVAO?n 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 09/12/08 AST SURVEY FORM