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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: USS' OE�W- &ytrlLQ' - JeL'1AC M4IA�, Page of G_- Facility Address: City: � Insp tion gate: l 6 . AGI, ` t v4 &0 , 'SSG l r l -7 0 0 GI FA#: ^ PR#: L/ Program Element: Cq D D leS 3 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. (I Tank (2820) ❑ Containers (2821) #of Containers: TA#: _ r,-I g�j� S' 1 Total Capacity: �-b0 gallons Product Type: U�e o 0/� - (per tank or cumulative for containers by product type) 2100 0 h Install Date: L V X Tank (2820) ❑ Containers (2821) "of Containers: 2 Total Capacity: _ D_0 gallonsProduct Type: S- 4-to W Nttnl O/ (per lank or cumulative for containers by product type) Install Date: Y Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: 2 gallons Product Type: S- C4 6 i^1 AJ e11/0 CVC (per tank or cumulative for containers by product type) /tet Install Date: (l IX Tank (2820) ❑ Containers (2821) #of Containers: TA#: )96-1 IR- 4 Total Capacity: Z-� gallons Product Type: A,% M1-6/�i (�% L (per tank or cumulative for containers by product type) Install Date: -2, 001 �C Tank (2820) ❑ Containers (2821) #of Containers: TA#: �[ $' , 5 Total Capacity: ( ( O gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: (yja gallons Total Capacity for Site: �� { Qgallons Comments: LEHDEector Reviewed ` -n' Date: Entered Date: E By Initial: V o f 0 By Initial: CL *AbovegrolUnd storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. O "Container means a storage device designed to be moved when full. Eno 2s-a1 09/12/08 AST SURVEY FORM