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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: U 5 Page _ of Facility Address: City: Inspectign DtQ: 'Z dsq I OS i FA#: PR#: Programlement: d5� 2 t5 Tank/Container Information Complet or 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) 11 Containers (2821) #of Containers: TA#: 1 t- Product Type: Total Capacity: 0 O gallons �Ta (per tank or cumulative for containers by product type) Install Date: Ca/Tank (2820) ❑ Containers (2821) #of Containers: TA#: I 2 Product Type: Total Capacity: 0 0 gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity: l>�'Tank (2820) ElContainers (2821) #of Containers: T #: /`7�1' (� 3 0/ e" gallons Product Type: (per tank or cumulative for containers by product type) Install Date: [I Tank (2820) ElContainers (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: gallons Product Type: (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: /L✓ By Initial: uvtlj , •\d 04) 1 By Initial: 02 /l "`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