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1, SAN JOAQUIN COUNTY ..r 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: s v Page l of l / G UAiL LAK.G FacilityAddress: City: Inspectio Dat z3Q22/ NAL B LVO w/.y oy FA#: BB� C VCO PR#:�1� Program Element: Tank/Container Information 8S Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks`and containers". Complete one box for each tank or each cumulative container product type. E}'ank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: 7—/ 0 gallons Product Type: 022 (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 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 Por 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: v((� gallons Total Capacity for Site: ZlC7 gallons Comments: 73 EHD Inspector Reviewed Date: Entered Date: By Initial: By Initial: /� '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