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SAN JOAQUIN COUNTY .,o 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: �U L 7-IJ U/S Page _ of Facility Address: + City: Inspectl at - 19 gS Sr ArF � ,iGL At1 D� FA if: PR#: Program Ele en 6 v �Kos3o 1-7o Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 11,320 gallons in tanks* and containers". Complete one box for each tank or each cumulative container product type. Or Tank (2820) ❑ Containers (2821) #of Containers: qr TA#: 1 Z c� Product Type: D Total Capacity: d gallons .4 (per tank or cumulative for containers by product type) Install Date: El Tank (2820) Oor ontainers (2821) #of Containers: TAM 2 allons �_g Product Type: 4/a .TTS 6/ Total Capacity: ) (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 3 Total Capacity: gallons Product Type: (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: Z gallons Total Capacity for Site: 2 S gallons Comments: EHD Inspector: ^ Reviewed Date: Entered Date: L' By Initial: By Initial: *Aboveground storage_taKk 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 29-01 AST SURVEY FORM 09/12/08