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5 `* _ SAN JOApUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT R Y 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: / TU C 13 t t it Page of L_ Facility Address: City: Inspection Data: S Z = LG nI A r%1 r74Z FA#: I 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) ❑ Containers (2821) #of Containers: TA#: j � � _ �/� Total Capacity: gallons Product Type. _..yD - T (per tank or cumulative for containers by product t pe) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) I 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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: r ElTank (2820) ElContainers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: i (per tank or cumulative For containers by product type) Instal! Date: _ 1 Total Capacity this Page: gauons TotalaCapacity for Site: gallons Comments: i- I 5 ! EHD Inspector: Reviewed Date: EnteredDate: By Initial: ti , �{ By Initial: "'Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. I "Container means a storage device designed to be moved when full.- EHD 28-Of V 09112!08 AST SURVEY FORM