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SAN.1'OAQUIN 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 f - I Z Page.--.,—/— of Facility Address: City: Inspe op Dat FA#: PR#: _ Progrdm EI en D �Jr 2 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 roduct t e. Tank (2820) ❑ Containers (2821) #of Containers: y TA#: 1Product Type:_ae _,I Total Capacity: �5-00 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulabve for containers by product type) Install Date: El Tank (2820) EJContainers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: s (per tank or cumulative for containers by product type) Install Date: F-1Tank (2820) El Containers (2821) #of Containers: ti TA#: 4 Product Type:, Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: Capacity: Product Type: Total Ca p y gallons (per tank or cumulative for containers by product type) Install Date: I. Total Capacity this Page: gallons Total Capacity for Site. gallons r i. 96mments: lr y�A- - E o !� 12- t EMD Inspector: Reviewed Date: Entered Date: �C3y Initial: 10:i;D.44� t3y initial: *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. E EHD 28-01 AST SURVEY FORM 091121oa