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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: i �f �//�V ��1� ArJ G J'1 / ' �J V1VPage , Facility Address: City: Inspection Date: FA#: (0 PR#: Program Element: © a o !?(4P197 1� 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 Product Type: Total Capacity: �� gallons (per tank or cumulative for containers by product type) Install Date: ID/Tank (2820) ❑ Containers (2821) #of Containers: TA#: oZ 2 r Product Type: Total Capacity: s� 1:q gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) L1Containers (2821) #of Containers: TA#: 3 ' Vr Product Type: Total Capacity: �: gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: 06-/ `]`�7 T 4 -r� Product Type: Total Capacity: ��--�) gallons (per tank or cumulative for containers by product type) Install Date: ?tel J ❑ 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: Entered Date: By Initial: By Initial: /J 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