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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main 029 Telephone:(209)468-3420 Fax.,t, Stockton, CA 3 (209)468 3 33 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: n -Z��Cc'�S� 011-1VC/�1o�7 -7Y0 . Page a of Facility Address: :City Inspection Date: FA M q C� PR _ Program Element: ICvc, I -7 - Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 11,320 gallons in tanks`and containers". Complete one box for each tank or each cumulative container product type. ❑ Tank (2820) YC��ontainers (2821) #of Containers: / TAM 1 Product Type: Total Capacity: �r-5gallons YPe� � S C' (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 2Product Type: Total Capacity: gallons (per tank or cumulative—for contamers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative formntainers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 4 Product Total Capacity: gallons Type: (per tank or cumulativeforcontainers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: J J gauons Total Capacity for site: 2-7 t�7 gallons Comments: tZL�f2 ��J EHD I ector: _ Reviewed J,u Date: Entered Date: By Initial: R rl+ �f {/1111 By Initial: 1� A ovegr d storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. --c'onti(r(er means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM