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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: Ur�'I'1:5 U S A /V D Page � of Facility Address: n- City: Inspec ion D e: Q Lrl,EI� I 2/ b FA#: PR#: Program ETe Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 'e-1,320 gallons in tanks"and containers". Complete one box for each tank or each cumulative container eroduct type. k #of Containers: TA#: ank (2820) ❑ Containers (2821) , 1a .c_D i F Total Capacity: �6 _ -V gallons Product Type: (per tank or cumulative for containers by product type) Install Date: E ❑ Tank (2820) ElContainers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ElTank (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 Total Capacity: gallons Product Type: (per tank or cumulative for cbnlainers by product type) Install Date: A. ❑ Tank (2820) ❑ Containers (2821] #of Containers: TA#: 5 Total Capacity: gallons Product Te: (per tank or cumulative for containers by product type) Install Date:r Total Capacity this Page: '7 gailons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: i� Entered Date: By initial: - c 1 By Initial: r "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. i "Container means a storage device designed to be moved when full. r r EHD 28-01 AST SURVEY FORM 09/12/08