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y,r SAN JOAQUIN COUNTY tNVIRONMENTAL 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: fJUdTAY Sl*d/% /LI Page of Facility Add ss: City: Inspec o6 Date� • / n/ Si FA#: / PRProortim Element _ . q p Tank/Container Information c. S Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks` and containers". Com I e one box for each tank or each cumulative container product type. ❑ Tank (2820) Containers (2821) #of Containers: j TA#: 1Product Type: 1&4 CrE T f2/ (/ Total Capacity: ZS0 gallons (per tank or cumulative for containers by protluct type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by 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: Z"5-0 gallons Total Capacity for Site: Z r gallons Comments: X 6- 4`Y c T me EHD Inspector: Reviewed Date: / Entered Date: By Initial: it„-'LCf-( By Initial /_ 0 'Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. !L "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08