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%- ,W 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: G N W( G FL) Page of Facility Address: City: Inspectlo ate: o// F,/ BHT M)4,47 & 7 Z7�0 FA A: / 7/ 0 ? 7/ PR«: 6 n Program Ele.melt: 0 (/ 2 Ay L7�o 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. 9,1eank (2820) ❑ Containers (2821) #of Containers: TA#: 1Product Type: /y S ,� Total Capacity: J 61-Cm;" gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: S':fl-b gallons Product Type: 0 / (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ®'Containers (2821) #of Containers: TA#: 3 Product Type: �q;— 4 �/7/I/ O/ u Total Capacity: gallons (per tank or cumulative for containe 0by product type) Install Date: ❑ Tank (2820) C�'�ontainers (2821) #of Containers: _� TA#: 4 Product Type: J�iA S�� ' U Total Capacity: �gallons (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: gallons Total Capacity for Site: kr gallons Comments: EHD Inspector: Reviewed + Date: Entered Date: By initial: VA '�_1l`_� By Initial: i '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