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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: V K NJ' UG Page of — Facility Address: Ci : Inspection Date FA #: PR M Progr m Element: 0 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) El (2821) #of Containers: TA#: � 1 Total Capacity: 0 p 7 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: L�Yfank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: % D d gallons Product Type:,/ (per tank or cumulative for containers by product type) Install Date: i Tank (2820) ❑ Containers (2821) #of Containers: TA#: 0 5)gq�� 3Product Total Capacity: gallons Type: �1�iC (per tank or cumulative for containers by product type) Install Date: ± Tank (2820) ❑ Containers (2821) #of Containers: TA#:� 4 Total Capacity: gallons Product Type: for (per tank or cumulative con ainers by product type) Install Date: i Tank (2820) El Containers (2821) #of Containers: n TA#: �� (2�- �{ /�� 5 Product Type: ,(/✓� Total Capacity: / 0gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 17'- gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: By Initial:iGl_0°f� Entered Date: By 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