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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.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility-Name: I -� U��✓,�, f �ttll �ti'�� Page 2. of G "'� I (1f Facility Address: ! City: , ' Inspection Date: �� �/�{ 27 Z -LSyl FA a: PR M Program Element: J 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) loontainers (2821) #of Containers: TA#: A5) New 1 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) r Install Date: - t ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: S galloTotal Capacity for Site: "" ns 3 _3gallons Comments: EHD Inspector: Reviewed Date: Entered Date: n By Initial: I By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. D "Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM