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r . �. SAN JOAQUIN COUNTY s �. .� 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 Nam V e C Page j of ,d /gej Facility Address: City: Inspection Date: o ,� r v FA M. J / M Program Element: 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. Tank (2820) ❑ Containers (2821) #of.Containers:. TA#: 1 Total Capacity: 500 gallons Product Type: F . J (per tank or cumulative for containers by product type) ` Install Date: U,-tank (2820) ❑ Containers (2821) #of Containers: / TA#: i 2 Product Type: zi..t.&. Total Capacity: 2- gallons (per tank or cumulative for containers by product type) Install Date: Dank (2820) ❑ Containers (2821) #of Containers: TA#: 3 --� . Product Type: Total Capacity: gallons . 'E (per tank or cumulative for containers byproduct type) Install Dater Containers: ,,atk (2820) ❑ #of Containers {2$21) u, TA#: 4 l Product Type: T�tal Capacity: gallons ils {per tank or cumulative for containers by product type} Install Date: ❑ Tank (2820) ❑ Containers (2821) #of s€Containers: TA#: 5 Total Capacity: gallons Product Type: i (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: - gallons;} Total Capacity for Site: gallons Comments: ra S s .c EHD Inspector. ReviewedI Date: Entered Date: IF-10 I By Initial: �.a- By Initial: Aboveground storage tank means a tank that has the capacity to store 55 gallons or more f petroleum. "Container means a storage device designed to be moved when full. \HD 28-01 AST SURVEY FORM 112108 �"