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SAN JOAQt1IN 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 Name: q-Z t Z �1-�y 1 'V 1✓1 :Page t� of Facility Address: City: IInsp tion ate: 2 2Z r� S L 1G til " `a FA M PR M Program Element: z� V.o Tank/Container Information Complete for all sites with cumulative aboveground storage of'petroleum 21,320 gallons in tanks*and containers**. Complete one bok for each tank or each cumulative container Broduct t e. #of Containers: TA#: I r Tank (2820) - ❑ Containers (2821) 1Product Type:,� v/L _• Total Capacity: OS& U gallons (per tank or cumulative for.containers by product type) Install Date: 1J N� ❑_Tank (2820) -Containers,(2821) #of.Containers: TA#:4 2 Product Type: rI f3 Z Total Capacity: �(, l� gallons . (per tank or cumulative for containers by product type) Install.Date: #of Containers:. TA#: ❑ Tank (2820) ❑ Containers (2821) 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑' Tank (2820) ❑ Containers (2821) #of Containers: TAM l 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: } 0- Tank (2820) ❑ Containers (2821) #of-Containers: TA#: 5 . Product Type: Total Capacity: gallons a (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: (�(g� gallons Total Capacity for Site: gallons Comments: For GV fur Vin, F L, yz, 4--L Kn EHD In ctor: Reviewed Date: Entered Date: By Initial: ,•"�.t o By Initial: r p I p *Abovegroullnd storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. 0 "Container means a storage device designed to be:moved when full. EHD 28-Ot 09112/08 AST SURVEY FORM