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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: A Z,6, V//fG XA6Q I Page _L_ of Facility Address: city: Inspecti a FA#: PR#: _ Program Ele t: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1,320 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 C' Product Type: CL 14 Total Capacity: � � �� gallons (per tank or cumulative for containers by product type) Install Date: W/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (,%� `] (per tank or cumulative for containers by product type) Install Date: IP/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 -17Product Type: Total Capacity: 5 - gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) Ycontainers (2821) #of Containers: TA#: 4 Product Type: jL L it l%' � L Total Capacity: ��_gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) 0 Containers (2821) #of Containers: �_ TA#: ' 5 Total Capacity: _ gallons Product Tyl (per tank or cumulative for cofffain'ers by product type) Install Date: Total Capacity this Page: gallonsl Total Capacity for g;+, �� gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: _?) ,�°� By Initial: Al//'�!� *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