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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: t✓ plvG Page _ of Facility Address: City: Inspectio Date- C)C.; ate:UG - U p 3I FA#: PR#: Progra �ma�tt;, 17 Z2 �D6,c 3 2 SV 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. E2 Tank (2820) ❑ Containers (2821) #of Containers: TA#: j 1Product Type: Total Capacity: 19&'2067 gallons (per tank or cumulative for containers by product type) Install Date: �ank (2820) El Containers (2821) #of Containers: TA#: 2 Total Capacity: S gallons Product Type: �7 (per tank or cumulative for containers by product type) Install Date: Tank (2820) ElContainers (2821) #of Containers: TA#: 3 Total Capacity: �' gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Mainers (2821) #of Containers: &XD TA#:4 Product Type: Total Capacity: �� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: Z.S`?.l gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: ✓ gallons Comments: P (?2-q) 14 9 2 L? Finspectol: Reviewed Date: Entered , /n Date: By Initial: Olga r By Initial: AY) *Atveground sto ge tank means a tank that has the capacity to store 55 g Ilons or more ofvpetroleum. **Con ans a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08