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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: /va M-5' 11V4 T g A C -_ C: / Page z- of 7. -- Facility Address: City: z 11'21q G i �lr k Inspectim o D te: _7o 0� 12 FA #: % r s-- 20 PR #: Progra E e l �n1�) 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. #of Containers: TA#: El Tank(2820) containers (2821) � 1 Product Type. /Vii. SCS Cr Total Capacity: 5;j- gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (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: S gallons Total Capacity for Site: gallons Comments: EHD Inspector: ^ Reviewed Date: By Initial: Entered Datefa. : By Initial: B ✓L� nUUvCyivuiiu swicaye 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 09/12/08/08