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SAN JOAOUIN 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: uyl G b CAI I " Page of–, -- Facilit dress: City: Ins ection Date: FA#: 2 � q �� PR#: 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. ❑ Tank (2820) �b Containers (2821) #of Containers: TA#: z'5) 9'9'�� 1Product Type: kli,,l Zd - C1 Total Capacity: gallons (per tank or cumulative for conta'IRer R---t type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: — TA#: R 2Product Type: Total Capacity: gallons ` (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Z Containers (2821) #of Containers: TA#: 3 Total Capacity: Product Type: 1;/'UMk/ p Y� gallons (per tank or cumulative for con ainers by product type) Install Date: ❑ Tank (2820) /❑ Containers (2821) #of Containers: TA#: LPj--I R l 5 4 Product Type: (jl� Total Capacity: gallons (per tank or cumulative for c n ainers 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: gallons Total Capacity for Site: � gallons Comments: EHD Inspector: Reviewed Date: Entered DateTP pc� i Ci By Initial: �,Z�f, t d By Initial: �°,r ��"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 09/12/08 AST SURVEY FORM