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fia .r SAN JOAQUtN 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: v i g !!N.!-D ! S 1 z U I<A Page of Facility Address: Z� � /Q%� City: Inspe�iMt r� I FA M PR M Progra Elem n 6 3 SJ 1 ® . r S Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum al,320 gallons in tanks*and containers". Complete one box for each tank or each cumulative container,product type. Tank (2820) ❑ Containers (2821) #of Containers: 1 Total Capacity: gallons Product Type: (per tank or cumulative for containers byproduct type) Install Date: ❑ Tank (2820). ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (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: ElTank (2820) El 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: / �.�!-� gallons Total Capacity for Site:` gallons Comments: 5 � N &442 EHD Inspector: _7_[Reviewed Date: Entered Dale: 8y Initial: ft`_`f�.l;� By Initial: !� *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