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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 -r l S -PO 6r-� Page of Facility Address: City: Inspectio Date: FA #: /7 PR M Program Element: 2q d 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#: $ Tp 1 Total Capacity: �� gallons s Product Type: �� S (per tank or cumulative for containers by product type) Install Date: IJ'Tank (2820) ❑ Containers (2821) #of Containers: TA#. 4,A 2O � Product Type: Total Capacity: .? gallons (per tank or cumulative for containers by product type) Install Date: U- Tank (2820) ❑ Containers (2821) *of Containers: TA#: 3 Total Capacity: ��/`� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: D"fank (2820) ❑ Containers (2821) #of Containers: TA#: 4Product Total Capacity: ?=-221' gallons Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ontainers (2821) #of Containers: TA#::a )9,fi- L L D 5 Product Type: Total Capacity: //12 gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: _4 gallons Comments: EHD Inspector: c . Reviewed Date: By Initial: yy� .v Entered By Initial: Date: �6 D *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