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SAN JOAQUIN COUNTY -.s 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: nUAIJJt o P Page _of Facility Address: cif InspectionFA 0: PR X: Program Element: p !te: q 5 CC) G z/' YD./ Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks*and containers". Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: ZJ O gallons Product Type: P-7 (per tank or cumulative for containers by product type) Install Date: B/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2Total Capacity: if 8 gallons Product Type: � J (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 Total Capacity: gallons Product Type: (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: gallons Total Capacity for Site: D gallons Comments: EHD Inspector: Reviewed Date: t0'oAi Entered al Date 0 By Initial: ll-LA *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. EHD 28-01 AST SURVEY FORM 09/12/08