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I SAN.IOAQUEN 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: Dn V/1) 141►1 Page L—of Facility Address: City: Inspection Date- 9 9 • RWN ) ZA 4 FA#: PR#: Prog nt: a__ _.�2 z 0 Tank/Container information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks`and containers". Com fete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: gallons Product Type: _ (per tank or cumulative for nters by product type) Install Date: e /Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: Product Type: gallons (per tank or cumulative for containers by product type) Install Date: rank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: 0_0 Product Type: 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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector: =eviewed Date: Entered Date: Initial: , L�, b•0141 By Initial: If 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 08!12108 '_