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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: U f Tr 12 J 7 A 6 Page Z of Z Facility Address: City: Inspection Date: (' FA#: PR M Program Element: �`�� I I -L q 3.1 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) ❑ Containers (2821) #of Containers: TA#: aA© 1 D Product Type: Lel/9 TD R 0 J Total Capacity: / gallons (per tank or cumulative for containers by product type) Install Date: R Tank (2820) ❑ Containers (2821) #of Containers: TA#: r9 6-1 2 Product Type: /q G! U Total Capacity: /' Z-0gallons (per tank or cumulative for containers by product type) Install Date: E Tank (2820) El Containers (2821) #of Containers: TA#: �,�(4B/��o 3 Product Type: Total Capacity: 7i4 ® gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (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: gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: 1 6 V By Initial: By Initial: �B *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 AST SURVEY FORM 09/12/08