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E 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: / tivi L t. i A I f L— /--IA f'� Page of r Facility Address: City: Inspec 'orn at�P FA #: PR M Program Element: '7 ter' 615a 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. Q/Tank (2820) ❑ Containers (2821) #of Containers: Tp*' 06-12 A5M 1 Total Capacity: ) ('Ir gallons Product Typv. J.�, .y % b T (per tank or cumulative for containers by product type) Install Date: [V (Tank (2820) ElContainers (2821) #of Containers: TA#: 2� Total Capacity: (i gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 1�l �� /� 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:Reviewed Date: By Initial: �� Cl''�• 00 Entered By Initial: I Date: A9 b *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