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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 Facilit Name: l/5 tl/ Page 2 of 2 Facility Address: City: Inspe ti n Date -" 14��-1 IZ::) FA M 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 product type. ElTank (2820) 2-/Containers (2821) #of Containers: TA#: 1 Product Type: AlzD fZY tl�7 Total Capacity: �;.�-� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total y: gallons Capacity: Product Type: p (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: � gallons Comments: EHD Inspector: Reviewed Date:---[Entered Date: By Initial: By Initial: *Abov ro/Ofd storage tank m a tank that has the capacity to store 55 gallons or more of petroleum. **Co er means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM