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SAN JOAQUIN COUNTY ., (ENVIRONMENTAL HEALTH DEPARTMENT 600'East Main Street,Stockton,CA 95202-302- Telephone:(209)468-3420 Fax:(209)468-3433 Web.www,sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: GK'S 5 —J-,q/�✓��'7` Page of Facility,Address: City: . Inspectio Date: 2 FA#:#: R#: Program Ele e t 3 09 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., ❑ Tank (2820) Containers (2821) #of Containers: t TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: 2-/ 0 gallons T. (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type.'. Total Capacity: gallons I - - (per tank or cumulative for containers by product type) Install Date:. ❑ Tank (2820) ❑'Containers (2821) #of Containers: TA#'- (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: gallons _, (per tank or cumulative for containers by product type) 'Install-Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity:. . gallons (per tank or cumulative for containers by product type) Install Date: j ❑ Tank (2820) ❑ Containers (2821)' #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: x - gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: Z1 O gallons Comments: ;a t EHD Inspector: _ Reviewed Date: -Entered )? Date By Initial: Cf, ,( By Initial: ' • ll1T�-�� } EHD 28-01 01/16/08