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SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTME14: 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: /2A, & T 12 V G/L G T 12 Page of Facility Address: City: Inspe to Date: r p 7/ ' 1 FA#: PR#: Pr gram Element: 0 0 o D 20 SW /%. 2k 3 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum Z 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. P-'fa (2820) ❑ Containers(2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) I Product Type: Total Capacity: gallons gallons (per tank or cumulative for containers by product type) Install Date: Lank(2820Xgallons (2821) #of Containers: TA#: /q�(le ! I6 (>250 gallons) 50 gallons) 2 Product Type: C'Total Capacity: gallons (per tank or cumulatict type) Install Date' ®Plank(2820) ❑ Containers (2821) #of Containers: TA#: 196-11a ll'lo 3 Product T (>250 gallons) (>55 gallons and<50 gallons) Type: !419 Total Capacity: gallons (per tank or cumulative or containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative far byproduct type) Install Date: Total Capacity this Pag !tS C d gallons Total Capacity for Site: ,56 gallons uAly wuo o ` CT1 EFID Inspector: D Reviewedate' Entered Date I By Initial: �_ S F7 By Initial EHD 28-01 01/16/08