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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: �_ 1 N U,S�j �j(� m t k Page � of Facility Address: Cit Inspection Date: L(jl/ '^ • l U FA M PR M Program Element: 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. ank (2820) ElContainers (2821) #of Containers: TA#: 1 otal Capacity: V �� gallons Product Type: k,"I ) A m I+X' (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2Product Total Capacity: gallons Type: = (per tank or cumulative for containers by product type) Install Date: KTank(2820) ❑Containers (2821) #of Containers: TA#:�� 3 Total Capacity: n gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: T�A#: 06-1 q 4 Total Capacity: gallons Product Type: �1�! X �� lil (61 (per tank or cumulative for containers by product type) Install Date: 5 Tank (2820) ❑ Containers (2821) #of Containers: TA#: `7 1 :- Product Type: Total Ca Capacity: p Y• gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons T Total Capacity for Site: �;& M2— gallons Comments: EHD Inspector: Reviewed By Initial: Date: Entered Date: By Initial: *Abovegrou tl stars a tank y� (/ g eans a an that has the capacity to store 55 gallons or more o petroleum. **Container means a storage device designed to be moved when full. i' EHD 28-01 09/12/08 AST SURVEY FORM