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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: Pageof j Facility Address: City: Inspecti ate: o N- �c�v 0 FA#: PR M Probrim Elem t: 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. O'Tank (2820) 1:1 Containers (2821) #of Containers: T(/A#: �S/co' 1 gallons Product Type: �\otal Capacity: D \ . (per tank or cumulative for containers by product type) Install Date: GYTank (2820) ❑ Containers (2821) #of Containers: TA#: 4R `7 L D 2 Zj Product Type: L+—/� S �/ Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: 'Tank (2820) ❑ Containers (2821) #of Containers: TAJ#: 1 $-711 3 Total Capacity: 2 41ele gallons Product Type: (per tank or cumulative for co ainers by product type) Install Date: ❑ Tank (2820) 2 4ontainers (2821) #of Containers: .S TA#: D 1 4 n Product Typ �D� 0/ U Total Capacity: � /,r gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) D Containers (2821) #of Containers: TA#: SSI` -7 L 3 5 Total Capacity: -7 Jr� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 2 gallons Total Capacity for Site: /3 �� gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: VA By Initial: ✓l / "Aboveground storage-tank means a tank that has the capacity to store 55 gallons or more of petroleum. O� l "*Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08