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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: l r -R. /'VG Page of Facility Address: Ci 12-3 2 LG v �v tor -'a T l� Inspect' n D t7:7/ / , FA #: PR M Pro Elemt: d �3 0 (a 3 3 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. El Tank(2820) L�-Containers (2821) #of Containers: _ Z TA#16-) q'-�.2 `3 1 r- Product Type: ��' / 41 Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: LZh q�a2�% 2 j� G O Product Type: ��1a- Total Capacity: / 4 C9 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Zen S Total Capacity: ��/-fl gallons ,/ (per tank or cumulative for containers by product type) Install Date: ank (2820) El Containers (2821) #of Containers: T 4 Total Capacity: S p- e-? gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) DP ontainers (2821) #of Containers: TA#: t 3 3� 5 3dgallons Product Type: Total Capacity: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: I / a gallons Total Capacity for Site: �� `f gallons Comments: V) /✓ /'was g/e, 2� 6 Z' oar s EHD Inspector: Reviewed Date: �y By Initial: 0\ "1'l Entered Date: By Initial: O *Aboveground storage tank means a tank that has the capacity to store 55 gallons or morelof petroleum. / **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08