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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: V6N DIk SEN PMS- Page—Lof Facility Address: City: Insp cti !ge Q �p I 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. El Tank (2820) !1 Containers (2821) #of Containers: TA#: 1 Total Capacity: 5-1 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: D Tank (2820) ❑ Containers (2821) #of Containers: TA#: I �S 27 (� 2 Product Type: Total Capacity: J gallons (per to k or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: L9 6-1 ? a 3Product Total Capacity: '0-6gallons Type: (per tank or cumulative for containers by product type) Install Date: ❑ Containers #of Containers: TA#: DSS( gg 5?/Tank (2820) (2821) 4 Total Capacity: / d O0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ontainers (2821) #of Containers: � TA#: 5 Total Capacity: j`"� gallons Product Type: �f � r C� (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: r gallons I Total Capacity for Site: gallons Comments: EHD Inspector: /a - Reviewed Date: By Initial: Entered By By Initial: Date: *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