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A 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: VS O NS 3 � -� 12 % Page _L_ of Facility Address: .� City: Inspection ate:. FA #: 3 �6S PR #: 063D)5 Prog amElement: z8�P 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. ank (2820) ❑ Containers (2821) #of Containers: T d 57/ c3 1 a D Product Type: Total Capacity: %0gallons (per tank or cumulative for containers by product type) Install Date: CW/Tank (2820) ❑ Containers (2821) #of Containers: TyA#: 2 Total Capacity:gallons Product Type: ✓C (per tank or cumulative for ntainers by roduct type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: ..1 � gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1916-rq5-S-o2_ 4 y Product Type: S Total Capacity: "2 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ontainers (2821) #of Containers:y TA#: 5 Product Type: &ZA Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: `Z 7 gallons Comments: EHD Inspect r: Reviewed1 • �) Date: By Initial: 1 •$� Entered Date: By Initial: WI r *Abovegro stora ank 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 09/12/08