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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 FOPM Facility Name: Page of e VrV 0 ee W1l-, Facility Address: 2 2 S GrSSbWI %2d . City: �Y� tion Da e: Inspe2 4� � FA #: PR #: a o� 1 C5 � �--s I Program Element: 2g a4 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: OD TA#: 1 Total Capacity: � �� gallons Product Type: i ,I LiDirl (per tank or cumulative for containers 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: p y: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: (V Cj Q gallons Total Capacity for Site: %, '570 o4 gallons Comments: EHD In ect Reviewed Date: Entered Date: By Initial: By Initial: D *A brMVIP hi inri c4nronc 4�nL a4 a �__ . ��- •.�. n 11. a Lai r\ u ial i IaS a ie Capdcrty to store o5 gallons or more' of petroleum. ` "'Co ainer means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM