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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 Facilitv Name: . Lk /14 t-lk%x— Se roe C -e S --rvIC. Page—(— of 1 Facility Address: City: 4 N . J aS�2 � dC� UVA Inspeection Date: FA M PR #: Program Element: 2�3 I 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. id Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: N 220 gallons Product Type: k (per tank or cumulative for containers by product type) L Install Date: (' I'1 F'-1� Tank (2820) ElContainers (2821) #of Containers: TA#: 2 N Total Capacity: r 5� gallons n� - Product Type: _ (per tank or cumulative for containers by product type) Install Date: un Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: /)& / S� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: in L ❑ Tank (2820) [Containers (2821) #of Containers: 2 3 TA/#: 4 Total Capacity: / I (� � gallons Product Type: a7� U -s- Vv cts-�Q (per tank or cumulative for containers by product type) Install Date: o ✓1, ❑ Tank (2820) X�Containers (2821) #of Containers: i TA#: M 5�- Total Capacity: c1 gallons Product Type: �\ tilar o S dq-S Q (per tank or cumulative for containers by product type) Install Date: l� Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed By Initial: Date: Entered Date: 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 C OVq AST SURVEY FORM D9/12/08/08