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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: �nl , % VA 76 /z- C -//C C L15 C,(r- Page -3- of Z1 Facility Address: City: ?,1 �, ; y , -Z' , ...3 r' 'q C'p,-j Inspection D te: / a7x -_;-/o J FA #: 0 3 �7®5� PR #: Fr�� Program Element: z 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: TA#: 0,±5_1 -7'�22 1 Product Type: ry-A Total Capacity: r � 4�) gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) [P Containers (2821) #of Containers: ?/ TA#: L-2(6-1 75190 2 Product Type: 14ZA Total Capacity: P 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 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 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: / (' By Initial: By Initial: *AbovegrounccTstorage 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