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f SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT T, 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: _ 1 V S T 5 m l T H~ 5/1117- I RAWCA Page / of Facility Ad,'- i 2-` � City: Inspectio "ter , �,�- �� ' FA#: PR#: PrograCn�Elem n Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum X1,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container product type. rl*�Tank (2820) 0 Containers (2821) #of Containers: V TA#: Total Capacity: Z b gallons Product Type: (per tank or cumulative for containers by product type) Install Date: C i ElTank (2820) 13 Containers (2821) #of Containers: TA#: 2 Product Type: E Total Capacity: gallons - "• •_— (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (2821) #af Containers: TA#; 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: EDTank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: y 2�� gallons Total Capacity for Site: Zgallons Comments: EHD Inspector: Reviewed Date: Entered Dale: By Initial: -3 j• By Initial: $ g *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08 i