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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: Gl'1 0- Page__q_ of Facility Address: City: Inspection Date: ID 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 product type. ❑ Tank (2820) ❑ Containers (2821) #of Containers: b TA#: 1 Total Capacity: `J 30gallons Product Type: (�A K3,i I � 0 I L/ v (per tank or cumulative for containers by product type) Install Date:(.So w ✓ 1 U tJ AXA-W 46 ❑ Tank (2820) ❑ Containers (2821) #of Containers: _ TA#: 2 Total Capacity: ),,2p Product Type:4( r I J, /ECAAA- gallons � �� v !� (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: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: *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 09/12/08 AST SURVEY FORM