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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: ku t.0 fblyw A4 Page l of Facility Address: -7 -10 S� Wl City: InspectiDate: //7'7 ( FA #: PR #: Program Elem nt: d1,5 ..2. ?A 31 Tank/Container Information 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: ;2,0 1 Product Type: I� Total Capacity: d gallons (per tank or cumulative for containers by product type) Install Date: �] Tank (2820) ❑ Containers (2821) #of Containers: TA#: &,!m Pq w 2 Product Type: ,� Total Capacity: �{-4-(� gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TnnA#: � ! a D q % 3 Product Type: !� Ge.��.0 Total Capacity: f gallons . (per tank or cumulative for containers by product type) Install Date: ® Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4Product Type: %i�� Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 5 gallonsl Total Capacity for Site: 6�O S gallons Comments: I _ ' 0o D () u A T �o W, .r EHD Inspector: Reviewed Date: Entered Date: 114 - By Initial: By Initial: I//� 7 ` "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 REV 06/03/10 AST SURVEY FORM