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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: AI/41 Page 4 ---of Facility Address: -7 City: & Inspects n Da I 2 / 2, FA #: PR #: I i 3 S" o6-&C� Program Elgment: -z 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) 11 Containers (2821) #of Containers: TA#: 6' u l Zo(Q 1 Total Capacity: 5M gallons Product Type: (per tank or cumulativefor cars 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 con ainers by product type) Install Date: Total Capacity this Page: gailonsl Total Capacity for Site: gallons Comments: EHD Inspect o' Reviewed Date: Date: By Initial: Tntered Initial: -1 --U/B Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. t "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08