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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: Vt/ ( L r� '') z.Cs Page L of Facility Address: r City: Inspec 'on D � 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. TA#: Containers: r ❑ Tank (2820) G�'`Containers (2821) #of _ 1 Total Capacity: �,_ gallons Product Type: 7 0 � 0 (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 9?Containers (2821) #of Containers: TA#: Duel g D q '� 2 '— �- Product Type: /'-2 n✓o i'-- 4i i � Total Capacity: � � gallons (per tank or cumulative for .on aine s by product type) Install Date: ❑ Tank (2820) ®'6ontainers (2821) #of Containers: ' TA#: 3 Total Capacity: Product Type: . 0 _ (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 Product Type: Total Capacity: gallons (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: d 'Aboveground storage tank means a tank that has the capacity to store 55 gallons or more o petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09!12/08/08