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SAN JOAQUIN COUNTY . .S 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 STORAGEIPROGRAM SURVEY FORM Facility Name: tZ0 Uf R S E /V Page of. Facility Address: City: Inspection'ate: S o �AHAAl T & : /M /0-� FA#: PRO: Program Element: Tank/Contginer 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 Type: Total Capacity: p gallons - (per tank or cumulative or containers by product type) Install Date: ❑ Tank (2820) El-Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons _ (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) I nstall Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) In Date: Total Capacity this Page: gallons Total"Capacity for Site: gallons Comments: EHD Inspector: Reviewed1 w �� Date: Entered Date: By Initial: Vv'v Zl�-� By Initial: 1/9 e J, D *Aboveground storage tank means a tank that has the capacity'to store 55 gallons or more bf petroleum. "Container means a storage device designed to be moved when full, EHD 28.01 AST SURVEY FORM 09112108