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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: , '1l L p7VG T CF /i eNL/U cvtf- r/vOlj /�l: Page -L— of�— Facility Addressy: City: I spectio Date, �..o /L/r:, c- c,7 vN� T t f c Cf/V/� l2 '41 X FA#: / I`� PR#: Program��D nt: D —�T " 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. Cer Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: /0 4 k) gallons Product Type: (per tank or cumulative for containers roduct type) Install Date: ,/ Dank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative fo coFt—ainerg by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 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: 1-1;7 C}�-Y-v gallons Total Capacity for Site: gallons Comments: t? EHD Inspector: Reviewed Date: Entered Date: By Initial: 4;.1K•0By Initial: "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