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• ;_ - SAN.1ROAQUIN COUNTY L 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: /oil1 G�fi T U GG /V I Page . of Facility Address: J4 City: Insp ct' n.Dat . S• n� r-�v' i J � 31 Q 9 FA#: PR#: 6o D Program e m t: t 7 -& t� 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. ZL Tank (2820) ElContainers (2821) #of Containers: 1 Total Capacity: . 3 jV Product Type: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) fiJ Contain rs (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: �, n (per tank or cumulative for containers Oy product type) Install Date: T ElTank (2820) PContainers.(282 1) #of Containers: TA#: 3 Product Type: Total Capacity: �'J �.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: 0Tank (2820) [1Containers (2821) #Containers: TA#: 5 Total Capacity: gallons Product Type:. (per tank or cumulative for containers by product type) Install Date: ' 1 Total Capacity this Page: gallons Total Capacity for Site: r gallons ; Comments: rte} ELUCCJy/ '- 2 EHD Inspector: Reviewed Date: Entered Date: ? By Initial: a. By Initial: C7 e go *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more bf petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 v 09/12t08 AST SURVEY FORM / t5