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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: l 0 1 IVA &'q R'41 S /N C/ Page of Facility Address: City: Inspectio Date: 0 1 z � (7104( FA#: PR#: Program Element: S D ^ r 2 yid 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) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: Total Capacity: 10006gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: _V ( $ 0Z_-I : 2 Product Type: Total Capacity: gallons (per tank or cumulative for co ainers by product type) Install Date: to/Tank (2820) ❑ Containers (2821) #of Containers: TA#: ��i 301 Product Type: /,L.�� Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: VTank (2820) ❑ Containers (2821) #of Containers: TA#: b f'JIR 27la 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAt — 2_ 5Total Capacity:p y gallons Product Type: �� (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 26 �� gallons Total Capacity for Site: Q gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: D *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