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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: r Page ;4- of ?� Facility Address: City: Inspect' n Dat hu� GV P FA#: PR If: Program Ele ent: 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. UY Tank (2820) ❑ Containers (2821) #of Containers: TA#: j,j—)q 43,:;2,1 Product Type: o Total Capacity: U gallons —r (per tank or cumulative for containers by product type) Install Date: O/T/ank (2820) ❑ Containers (2821) #of Containers: TA#: A 6-1 '13.3 Product Type: /��P ze�) 2� Total Capacity: (�O gallons _ (per tank or cumulative f containers by product type) Install Date: / " 0,-Tank (2820) ❑ Containers (2821) #of Containers: TA#: )1-3 F 3 Product Type: Total Capacity: gallons (per tank or cumulative for con finers by product type) Install Date: LYfank (2820) ElContainers (2821) #of Containers: TA#: 4 FProduct Type: Total Capacity: J 17-� gallons (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 containers by product type) Install Date: Total Capacity this Page: G1'6 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: 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 AST SURVEY FORM 09/12/08