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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 STORAGERROGRAM SURVEY FORM Facility Name: ]�� G �-r R, G i V c/ Page of Facility Address: j City: Inspect i n ate: f -2,01_qr- z 7 M FA#: PR#: PramI�� Z. 9 6 O u 7D._ tOOtr Tank/Container Information Compl to 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. Cl/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: (9/0 gallons Product Type: C; A S �T (per tank or cumulative for containers by product type) Install Date: r Tank (2820) 11Containers (2821) #of Containers: T 2 Total Capacity: 8 gallons Product Type: (per tank or cumulative for corifainers by product type) Install Date: I Tank (2820) ❑ Containers (2821) #of Containers: TA#: 35 -p Product Type: . Total Capacity: Z gallons ( (per tank or cumulative for containers by product type) Install Date: � ❑ Tank (2$20) L`'! Containers (2821) #of Containers: TA#: 4 Product Type: '�/4=1 Total Capacity: 5 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) In Date: ( Total Capacity this Page: / p gallons Total Capacity for Site: �a� gallons Comments: EHD Inspector: Reviewed Date: Entered Oate: By Initial: ,1, �_ d� By Initial: "tL foe i '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. li EHD 28-01 AST SURVEY FORM 09112/08