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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: AV t' �� Page of Facility Address: City: Inspection D e: N1 FE & _ //? 4 FA#: PR#: Program Element: 295 Tank/Container Information Completell sites with cumulative aboveground storage of petroleum a1,320 gallons in tanks" and containers'". Com lete one box for each tank or each cumulative container eroduct type. Tank (2820) 13Containers (2821) #of Containers: TA#: r 1 Product Type: Total Capacity: 0o 0 gallons (per tank or cumulative foTcontainers by product type) Install Date: ElTank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: i ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El Tank (2820) El Containers (2821) #of Containers: TA#: { Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ❑ Containers (2821) #af Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: $ Total Capacity this Page: , a �} gallons Total Capacity for Site: /�C�� gallons Comments: EHD Inspector: Reviewed Date: / r� Entered Date: V/J By Initial: 7`�" V"�� $y Initial: D I *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