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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT r 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: Page ! Of _ / S GIC To A/ r S Tf'l/�A/ Facility Address: & CAfipy �� City: �� Inspection D�t��O� FA#: PR#: Program Element: 9 /;78 D5a a © �8 � Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?-1,320 gallons in tanks"and Containers". Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 6111 1 Total Capacity: d d gallons Product Type: (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 cumulative for containers by product type) Install Date: El Tank (2820) ElContainers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: h (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (282 #of Containers: TA#: 8 Total Capacity: g Ilons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: J-1�16 gallons' Total Capacity for Site: d gallons Comments: xl—f ��d y J EHD Inspector: Reviewed ��{ hate: , [ Entered ,�/� Date: • By Initial: V�" l I7 U By Initial: t� `O -z�. *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. EHD 28-01 AST SURVEY FORM 03/12/08