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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: V % C,- /; � %� (T � TinfR, ' Page � of Facility Address: City: Inspect7i n Da � !f L r i / � L� T� �' �f�-� � , % FA #: PR #: Program Element:, ?9D5..50 1 q 2,_ ,. 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. ank (2820) ❑ Containers (2821) #of Containers: TA#: 06-1 1 Total Ca acit �� p y: gallons Product Type: �f�.S ,Y (per tank or cumulative for containe by product type) Install Date: L3 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: ` (�>C� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: / El Tank 'Containers #of Containers: / TA#: (2820) (2821) 3 Total Capacity: 5^S gallons Product Type: —1112 % (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: /g 5 ( 02 le Tank (2820) El Containers (2821) 4 Total Capacity: C-,6 gallons Product Type: h�� (% o —�—° (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: I'` gallons I Total Capacity for Site: gallons Comments: i EHD Inspector:? Reviewed ` Date: By Initial: `Jv t '1 •� Entered Date: 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