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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: l L� U A (�3 9 31( v Page % of Facility Address: City: s Inspe ti n Date: oqal l FA ," #: 3471 Prog� � n� 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) 11 Containers (2821) #of Containers: TA#: 1 Total Capacity: O C� �% gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Pr/Tank (2820) ❑ Containers (2821) #of Containers: TA#- 2 e9Product Total Capacity: /' C`�! -0 gallons Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#- S S� 3 Total Capacity: (2 gallons Product Type: 2�� (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: U�� gallons Total Capacity for Site: 3 ()-Cril gallons Comments: Z Ly — �' b EHD Inspector: t- Reviewed By Initial: Date: �� b,'�, ate, Entered Da By Initial: N D "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