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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 Na f� —/?Uck- 0p Page / of_-Z'- Facility Facility Address: City: Inspe tion Dat : 5 O S H FA#: 7�C- 2 /00&58Q /3 Program Element: 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#: S-E�?'Cf zv D 1 Product Type: /�D f UV D/ Total Capacity: 20 0 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: o2D f to 2D Product Type: /lt' f D f 07-1 Total Capacity: 2 O (� gallons (per tank or cumulative for containers by product type) Install Date: XTank (2820) ❑ Containers (2821) #of Containers: TA#: B/� 3 Product Type: /LIlj�� 1 Total Capacity: 20Q gallons (per tank or cumulative for containers by product type) Install Date: )X Tank (2820) ❑ Containers (2821) *of Containers: TA#: 4 '7'D Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Xcontainers (2821) #of Containers: TA#: 5 Total Capacity: ED J�5D gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: /�� gallons Comments: EHD 1 p e c t : _ ReviewedDate: Entered Date: By Initial: J'A 1� 1 `` By Initial: L / "A v round storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. ""C ntainer means a storage device designed to be moved when full. EHD 28-01 09/12/D8 AST SURVEY FORM