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F ' SAN JOAQUIN COUNTY '* . . I r a ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209) 468-3420 Fax: (209) 468-3433 Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: 0 ,� G i �l�LI 5 ;: Page l of Facility Address: f: City: / Inspecti n ate; b 1L "o"o jr_ E 0 2. r �� FA#: PR# Program Elem nt: le ' Tank/Contair er 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. Tank (2820) ' ❑ Containers (2821) #of Containers: c . T !' � � 1 gallons Product Type: Total Capacity: ® � (per tank or cumulative for containers by product type) y Install Date: �'h l,l ElTank (2820) ElContainers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: �t r' ElTank (2820) :. ElContainers (2821) #of Containers: TA#: 3 Total Capacity: . gallons Product Type: (per tank or cumulative for containers by product type) 1, Install Date: El Tank (2820) ElContainers (2821) #of Containers: TA#: e 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) III 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 1 Total Capacity for Site: gallons Comments: ,a rwv ''' "q cG' E EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 dallons or more of petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 ' AST SURVEY FORM 09112/08