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- j r 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`OROGRAM SURVEY FORM Facility Name: ' Page of / Go(3Le ViAZ-�y'AAP Facility Address: b City: Inspeti ryDate, S 7 / FA#: PR#: Program Ele ent: AM 1 v, zg b Tank/Container Information CompI to for all sites with cumulative aboveground storage of petroleum 'e-1,320 gallons in tanks*and containers". Complete one box for each tank or each cumulative container product tyRe. WTank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: _ Total Capacity: DO gallons (per tank or cumulative for c ntainers byproduct type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 11 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: / Z Ul/d G� r I EiD Inspector: Reviewed Date: Entered Date: C -• By Initial:' t- 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. EHp 28-01 i AST SURVEY FORM 09/12/08