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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(�: o G A 2 m S Page of Facility Address: City: Inspec ion Da e: i f o YiG1 T P4 �_r •tib D FA#: PR M Pro&b.Menjent. '7 vI OS 3,r,>q2830 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. d`Tank (2820) El Containers (2821) #of Containers: TA#: b,5 �jeif(o.r 1 Product Type: Total Capacity: o? gallons (per tank or cumulativefor containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: g6 �{ 2 Product Type: Q, Total Capacity: e) gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: T #: _Qb >' `� to 3 ProductT OA- Total Capacity: Type: (per tank or cumulative for containers by roduct type) Install Date: ❑ Tank (2820) L'/Containers (2821) #of Containers: �_ TA#: 4 Product Type: Total Capacity: 15� gallons (per tank or cumulative for containers by product type) Install Date: ElTank (2820) E Containers (2821) #of Containers: �_ TA#: / Total Capacity: 5 5 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 6 gallons Total Capacity for Site: o gallons Comments: EHD Inspector: Reviewed Date: Entered Date: C By Initial: ') 2j1 11 By Initial: B `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