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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTjQ,\l, 600 East Main Street, Stockton, CA 95202-3029 ` J Telephone: (209) 468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM is Facility Name: /J G Page -L of l/ Facility Address: City: Insp c' n te: D 2/ 0 FA C PR M Program Elem t: D L9 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#: a ' 1 Total Capacity: S' 0 fl gallons Product Type: S (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: to 2 Total Capacity: s�O gallons Product Type: (per tank or cumulative for containers by product type) Install Date: W--tank (2820) ❑ Containers (2821) "of Containers: / TA#: 3Product Type: �iy1 J7 Total Capacity: Sia gallons (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 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: f gallons Total Capacity for Site: s�Cl C� gallons Comments: EHD Inspector: Reviewed Date: ! Entered Dat . 6y Initial: •b.0 0� 6y Initial: �( O "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleu "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08