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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 Nam -� V E A V ft A lv G Page of Facility Address: Cit Inspecti n Date, � rLp cG� FA #: PR M Program Elem nt: ,6 D5a `Z a- �- 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) ❑ Containers (2821) #of Containers: TTAp#: 1 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ®/Tank (2820) ElContainers (2821) #of Containers: TA#: 2 Total Capacity: 4 r) gallons Product Type: (per tank or cumulative for containers by product type) Install Date: /Tank(2820) ❑ Containers (2821) #of Containers* TA#: 022 g' f f, S� 3 Total Capacity: 10 gallons Product Type: _/-� (per tank or cumulative for co tainers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (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: o' C'7 Q gallons Total Capacity for Site: gallonsC'7 Comments: EHD Inspector: / Reviewed By Initial: Date: �,1/0, f� Entered Date: By Initial: l `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