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SAN JOAQUIN COUNTY r } 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: L Lr0 A /14 GAMRX Page l of Facility Address: City: Inspec to Date: ROE Vag -Z, /-1/ A yr r, s C n (ail � Q FA#: PR#: Pro r EI a ti l 7 3l 950 .�_ ' Tank/Container Information Complete 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. �n1< (2820) ❑ Containers (282 1) #of Containers: TA#: 1 Product Type: _Z2 v Total Capacity: Z gallons (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: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: I 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ElContainers (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: -.Z� p gallons Total Capacity for Site: 2-&P�e gallons Comments: 6 C A ' E n IL Z� D EHD Inspector: Reviewed Date: Entered Date: ' By Initial: �,��. By Initial: ? /'?',A '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 09112/08 r