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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: �r C Page 2 of Facility Address: q5c2 AVS City: Inspection Date: `f sc,,,. /S vy FA #: PR #: Progra Elem nt: g 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#: 1Product Total Capacity: Z So gallons Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#:� ! g f 2 Total Capacity: S� gallons Type: 54Cp (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (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: 0 gallons Total Capacity for Site: Zs'Oo gallons Comments: EHD Ins ctor. Reviewed By Initial: Date: Entered By Initial: Date: !�( r78 �Aeground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. ** ntainer means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM osii2rna