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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.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: , / i ; v' t ` '�� Page ... of Facility Address. City: Inspe tion D e: FA#: PR Program Element: 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 roduct t e. '� #of Containers: 1 TA ISI Qr� ❑ Tank (2820) G�ontainers (2821) C1 ) 1 =� 5 Product Type: Total C gal /L (per tank or cumulative for containers by product type) Install Date: I\ t El Tank (2820) �fifainers (2821) #of Containers: ! TA#: _dam j &�Tj 2 "1 Product Type: Total Capacity: (; gallons �✓" CYIA! I-01 (per tank or cumulative for containers by product type) ,tj Install Date: ❑ Tank (2820) ❑"Containers (2821) #of Containers: TA#: 1 3 Total Capacity: Product Type: qa gallons I (per tank or c ❑ Tank (2820) E3`bontainers (2821) #of Containers.- _� TA#: 4Product Type: Q �/ Total Capacity: gallons Yp (per tank or cumulative for containers by product Install Date: r-I-ly ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for,containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: I� gallons Comments: _ EHD Ins�ecfq Reviewed `\j I Date: ttByntered Date: -" � By Initial: Initial: "Ab®Veground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. D .Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM