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ftSAN 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: SC v/T V1 5s Page of L— _1___ Facility Address: City: /�� Inspec ion Qate: FA #: / � PR #: D5 4 Progedm alem nt: 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 iner product type. *of Containers: TA#: ❑ Tank (2820) ErContainers (2821) 1gallons Total Capacity: s S' Product Type: (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: M" Tank (2820) ❑ Containers (2821) 2 Total Capacity: % o 0 gallons Product Type: (per tank or cumulative for containers by-product type) Install Date: #of Containers: TA#: LIQ Tank (2820) ❑ Containers (2821) 3 r Total Capacity: J � gallons Product Type: yy�---�– (per tank or cumulative for containers by product type) Install Date: Ly' Tank (2820) ElContainers (2821) #of Containers: TA# 4 Product Type: Total Capacity: gallons o iners by product (per tank or cumulative for ctype) 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: 0 gallons Comments: EHD Inspector: Reviewed By Initial: Date:/y� 5.��1 0" 1 Entered Date: By Initial: L2 L9 *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