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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 PROGRAM SURVEY FORM Facility Name: Y-5 Page Of 2 Facility A ress: City: Inspecti Da (ASO Lv- j�2 FA PR M Program Element: 03 1 Z 2 3 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. Ind Tank (2820) ❑ Containers (2821) #of Containers: T #: ��i /�'��v 1 Product Type: Total Capacity: /0 0 0 d gallons (per tank or cumulative for containers by product type) Install Date: I� Tank (2820) El Containers (2821) #of Containers: T : � �7D9'4p 2Product Type: Total Capacity: 5-&o gallons 01LAj-1 (per tank or cumulative for containers by product type) Install Date: E9'/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1`lf�'? 3 Total Capacity: Y&& gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 52/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: .. Total Capacity: 1-+�" gallons (per tank or cumulative for containers by product type) Install Date: lia Tank (2820) ElContainers (2821) #of Containers: TA#: 5 Total Capacity: 5 010 gallons Product Type: (per tank or cumulative for con ainers by product type) Install Date: yf/ Total Capacity this Page: 5 gallons Total Capacity for Site: i gallons Comments: 0 �r k4 � (3 z1 t/, 3 - z EHD Inspector: Reviewed Date: Entered Date c—, - By Initial: By Initial: Q *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more o petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08