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t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT J 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: r Z.1 G If(// �F/V/V//CL/�. �l�?/!� Page of [Facility Address: city: it 2 D ! &G�O n_p , y r� Inspfection Dace J PR#: Program EI oak Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z1,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: 1Product T _ Total Capacity o gallons Type: -''� ""i(per tank or cumulative for containers by product type) Install Date: ff Tank (2820 ❑ Containers 2821 #of Containers: TA#: 2i Product Type: Total Capacity: �5-pa gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: Product Type: p y: 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: 00 gallons Comments: EHD Inspector. Reviewed Date: Entered Date: By Initial: � By Initial: *Aboveground storage tank means a tank that has the capacity ito 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