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SAN JOAQUIN COUNTY , ENVIRONMENTAL HEALTH DEPARTMENTpp )) q East Main Street, Stockton,CA 95202-302$x" Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: l G G 1 f T1 U 01 age of Facility Address: -0/ZCity: Inspection Qate� /, 132P -rAfjC)x1d!=-D rFA#: -PR#: Progr/.aim��nt:� !� L� Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. Tank(2820) ❑ Containers (2821) #of Containers: -TA#:. (>250 gallons) (�-55 gallons and<250 gallons) Uo Product Type: Total Capacity: _ gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: :. TA#: (>250 gallons) - (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers:% TAM �+ (>250 gallons) (>55 gallons and<250 gallons), 4 Product Type: ' Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 5 - Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date:,- Total Capacity this Page: S—O-eP gallons Total Capacity for Site: gallons t Comments: a l.� Zn aN EHD Inspector: 4 % Reviewed + Date: Entered Date' By Initial: q ,�} �r'�. By Initial: EHD 2"1 01/16/08