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NEW SAN JOAQUIN COUNTY VA/ 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: 4�1/Z UA/4 FARM S /N G Page-,L-of Ir Facility Address: Clty: Inspection at A S" W r. ,✓z� 7V �� 1! FA#: O S ? PR#: Bjr� PrograZ V Tank/Container Information (D� L/i' Complete for all sites with cumulative aboveground storage of petroleum 11,320 gallons in tanks' and containers". Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: T, #: 1 Product Type: �►►CJ\ Total Capacity: gallons (per tank or cumulative for contemers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: 2 Total Capacity: 5 5 gallons Product Type: yYl i 5 d i JI (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: p 3 �4�� Total Capacity: gallons L Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: O 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: jM I -Z- /f✓ 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 09/12/08