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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: O /VG / Nr l�n dJ /1(' Page --14-- of Facility Address: (/ \/`IIty: r Inspectio ate: 3 6v0 �v � /SVG 1W11 FA#: 1 S—f PR#:10 5 ^ Program, 6091: E1@ e D O� ALU( 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) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: Total Capacity: � o c gallons (per tank or cumulative for containers by product typo) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product typo) 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: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (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: gallons Total Capacity for Site: gallons Comments: 1 -2 zo A /lr7 EHD Inspector: Reviewed Date: Entered Date: - By Initial: 2'S•fm By Initial: �B *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more f p roleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08