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Iftw SAN JOAQUIN COUNTY ,qw 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: tvl L LI A� C) YAC, Page _ of Facility Address: • CI : Inspectio Date: r VE G FA#: PR#: Program Element: rZ O 3 / 00�329q 727 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks`and containers". Complete one box for each tank or each cumulative container product type. El Tank (2820) LKContainers (2821) #of Containers: TA#: 1 Product Type: D.�n✓ Total Capacity: ISO gallons (per tank or cumulative for containers by product type) Install Date: E] Tank (2820) td Containers (2821) #of Containers: TA#: 2 Total Capacity: D gallons Product Type: �R S y 7 (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) .'ontainers (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 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: 3 s�� gallons Comments: &/A'07 v D/VS �U EHD Inspector: Reviewed Date: Entered Date: By Initial: aJ �Q•1- By Initial: 'Aboveground storage tank means a tank that has the capacity to store 55 gallons or more 6f petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 08/12/08