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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East.Main Street, Stockton, CA 95202-3029 Telephone:(209)458-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd E ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Nam f � �/A I�A� �V CJ � }� r _ [ C } Page sf ' 0�, tf f'S 1 !1i l,/ Facility Address: ity: Inspection Date: Lr FA#: PR#: Program Element: (0 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: TA#: D 1 Product Type: Total Capacity: 0-ob gallons (per tank or cumulative thr containers by product type) Install Date: I�Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 nj-&,I:& Total Capacity:. gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 2("'Tank (2820) ❑ Containers (2821) #of Containers: TAM 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date:. t1 �. Tank 2820 ❑ Containers 2821 #Containers: TA#: DJ 1`�`77T 4 Product Type: Total Capacity: 3—� gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ❑ Containers (2821) #af Containers: TA#: 6 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 3 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 AST SURVEY FORM