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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 STORAGEPROGRAM SURVEY FORM Facility Name: S 7-4-V1 i✓ ' - C`G JB'I 1�l� � Page of Facility Address: - City: Inspection ate: 0 d '" T FA M PR#: Program IEI me t: 33 0� 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) El Containers (2821) #of Containers: TA#: 1 Total Capacity: SO 0 gallons ' Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ElContainers (2821) #of Containers: TA#: 2 Total Capacity: _gallons Product Type: .( -- (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons n(' (per tank or cumulative for containers by product type) Install Date: s ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per lank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers:. TA#: t 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: O gallons., Total Capacity for Site: ZIP gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial L}!}_',0�p.,1 By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or mor of petroleum. *"Container means a storage device designed to be moved when full, EHD 28-01 AST SURVEY FORM 09112/08