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w SAN JOAQUIN COUNTY. ENVIRONMENTAL HEALTH DEPARTMENT 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'-'A&A - G , Page of Facility Andre s: City: Inspects n Dat z 9 o�1Nsa. r->(- / FA#: PR#: Prog m Ele ent. e z 3 �?' 2 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks'and containers". fl-'Tank (2820) � Complete one box for each tank or each cumulative container product type. 'f- Tank (2820) ❑ Containers (2821) #of Containers: TAS #f: 1 Total Capacity: 70-0 gallons Product Type: ��5 v (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2Product Type: Total Capacity: ,SO'd gallons (per tank or cumulative for containers by product type) Install Date: /Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: ��S R2 Total Capacity: 21 &0 gallons (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 11Containers (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: 0 0 gallons , Total Capacity for Site: 0 gallons Comments: J' EHD Inspector: Reviewed - `� Date: Entered Date' b By Initial: V 7,Cj- By Initial: . "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. EH0 28-01 AST SURVEY FORM 09/12/08