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r SAN JOAQUIN COUNTY � -ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main'Street, Stockton, CA 95202-3029 l Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Nam Q U.S WL _ Page of Facility Address: CityIx : Ins tion D te: /j �(�� J FA#: � Program Element: I Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum k1,320 gallons in tanks*and containers". Com lete one box for each tank or each cumulative container Eroduct type. 199Tank e. Tank (2820) ❑ Containers (2829) #of Containers: TA#: 1 Total Capacity• allans Product Type: AM (per tank or cumulative for containers byproduct type) Install Date: 'l'Tank (2820) '❑ Containers{2821) #of Containers: TAM 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date; ❑ Tank (2820) Containers (2821) .#of Containers: -e-3 TA#: 3 Total Capacity: 1 gallons Product Type: dI (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: 4Product Type: u C Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: r gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed . ,{ Date: Entered Dale: -AM 1__� . By Initial: hA By Initial: 'Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. "*Container means a storage device designed to be moved when full. EHb 28-01 09/12/08 AST.SURVEY FORM