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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN- 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: C U G W Ki C� /,A/� Page of �� Facility Address: City: /, Inspectio Date: 1.3 (og FA#: PR#: Progrard Element: Tank/Container Information Complet for all sites with cumulative aboveground storage of petroleum>1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. Tank(2820) ❑ Containers (2821) #of Containers: , TA#: 1,96"1 7 ,2� (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: I(2 C2 D fl gallons (per or cumulative for containers by product type) Install Date: jank (2820) ❑ Containers (2821) #of Containers: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: � Total Capacity: t 0 0 6 0 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: 3gallons T•- (per tank or cumulative for containers by product type) install Date: I AO i ank(2820) ❑ Containers (2821) #of Containers: TAH: D 5l '7 �ZS (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: �� r•�� dl Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: _ Total Capaciti this Page: 2 gallons Total Capacity for Site: gallons Comments: t EHD Inspector: di Reviewed , ` -`` Entered Date: Cv By Initial: 1�1``t 0-kLt, By Initial: B EHD 28-01 01/16/08