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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: /VT Page—_L�/�� /�� n�� e of Facility Address: city: Inspectio Uat : n FA#: ry PR#: -1 Program Elem t: zz 83 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. Q" Tank (2820) ❑ Containers (2821) #of Containers: TA#: le /Q 1 Product Type: /�✓� Total Capacity: 10 0 CJ gallons (per tank or cumulative for containers by product type) Install Date: P Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: r Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: V Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3Product Type: �A S g 7 Total Capacity: /UG 6 gallons (per tank or cumulative for containers by product type) Install Date: V/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1p (3 r 4 Total Capacity: J�) gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: 't/ TA#: 5 Total Capacity: // gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: l gallons Total Capacity for Site: 3 (5 gallons Comments: j�✓1rir� �3 a�-r EHD Inspector: Reviewed Date: Entered D te: C - 6 By Initial: ( �,�,� By Initial: l *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