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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: Page Facility Address: A City: Inspe ti te: 2 % of FA #:33� � 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. 1Product Tank (2820) ❑ Containers (2821) #of Containers: TA#. 1��j 7 1 1:7- ��p��✓LJ Total Capacity: C) t, �� gallons Type: (per tank or cumulative for containers by product type) Install Date: 2`Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: 1, t'l ,,� gallons (per tank or cumulative for containers by product type) Install Date: El Tank 2 'Containers #of Containers: � TA#: /9L/ `7r�z� (2820) (2821) 3Product S� Type: `�✓%; S T '` /1 l �J Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: 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: r C" gallons Total Capacity for Site: S , gallons Comments: EHD Inspector:% " j Reviewed By Initial: Date: Entered Date: By Initial: *Aboveground storagejarfk 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