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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 . of Facility Address. City -Inspect Y Det 2 2 S • 11 A/l/�t FA #: rK Program Element: Z8 � 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. P--fank (2820) ❑ Containers (2821) #of Containers: TA#: pzf l6_1 1 Total Capacity: �--tl�% gallons Product Type: (per tank or cumulative for containers by product type) Install Date: #of Containers: TA` Tank (2820) ElContainers (2821) 2Product Total Capacity: 3 S d gallons Type: (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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ 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: gallons Comments: L(zeOPIZAl t 8 EHD Inspector: eviewed 7ByInitial: `. � Date: r �1`�`' 'l��•�" 1 Entered Dat70?/ By Initial: D *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleunt. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08