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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: ._/ 0 V" s Page of Facility Address: City: 0 e>0 S- 14141'va D /Z S T/�— Inspection Date: l' 2 Y/0% FA #: PR #: Program Element: 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) LT"XContainers (2821) #of Containers: TA#: Of 1 Product Type: AI D `�%�� 67, Total Capacity: gallons (per tank or cumulative for con ainers by product type) Install Date: [P/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 06-1 .2 O 2Product Type: /�/1Cj / 01, (J Total Capacity: -94'�%' _gallons - (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (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: EHD Inspector: e Reviewed Date:Entered Date: By Initial: By Initial: MUOVegfOUHU StUiaye 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