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' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT r 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: d 9tg1vc- 1,d PVC/ Page _ I _ of–j— Facility Address: City: Inspectio at : 12 7 FA#: PR M ProgramEI ent: 53 a D5 o z a 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#: AITI 1 Total Capacity: _ l gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Sd Tank (2820) ❑ Containers (2821) #of Containers: TA#: 06-13 712(P 2 Total Capacity: j 6 a D gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Ell Tank (2820) ❑ Containers (2821) #of Containers: TA#- LA / 17D 7 3 Total Capacity: r 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 contai ers b 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: S-0 gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: V1Aj -)'J'0,01 By Initial: Q *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. U **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08