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SAN JOAQUIN COUNTY _ ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main street, . CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3 33 Web:www sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name; '��/� GLrtic- ' Q/ Q 7)'je. Page / of Facility Address: �j/ �r Dtty' (1 / / _ Inside ion Date: FAM: U/Y�CfLTZ1N� 7 /O O 45-e", PR#. Program Element: os2 07832 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. ❑ Tank (2820) Containers (2821) #of Containers: TA#: 4tsa1.?1 A r 1 Product Type' �'Qf71r p j� Total Capacity: r/�, OGC gallons (per tank or cumulative for cofiners by y--protluct type) Install Date: ❑ Tank (2820) (Containers (2821) #of Containers: I0 TA#: 2 Total Capacity: 5 6500 Product Type: /UlO/0 i'oj/�fjaj P y� r gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: ) 8 3 ProductType: e: rq P (J/ Total Capacity: �� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: 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#: 6 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: /,S� 2 7 1 j gallons Total Capacity for Site: 45 r Z cj gallons Comments: o-- EHD Ins eclor: Reviewed Date: Entered Date: By Initial: Ruv L.( If 11 By Initial: 1311 q // 'Ab egr nd storage tank mean a tank that has the capacity to store 55 gallons or more of petroleum. J ..Co ner means a storage device designed to be moved when full. EHD 28-01 06/12/08 AST SURVEY FORM