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tW4 SAN JOAQUIN COUNTY kw.„) 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 f g ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM i Facility Name: 1 G I< t i'll L G 1 'qr11S - V/�vl / r> S Page of Facility Address: City: InspTMI : 17 qG-- ��yL�� fids FA#. PR#: Program Ef ment: I 06 0-5,96P I 2 B Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z1,320 gallons in tanks*and containers**- f Complete one box for each tank or each cumulative container product type. VTank (2820) ElContainers (2821) #of Containers: - T 1 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 - Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity tythis Page: C gallonsTotal Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: VVI �•�. By Initial: �, 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. EHD 28-01 AST SURVEY FORM 09/12/08 ,;