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t, SAN JOAQUIN COUNTY `s 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: , Y- 5 / GIS O LQ S Page / of / Facility Address: (City: Inspection Date: o z/- Go tte-- 3- 07 FA#: PR#: Program 2195 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. ❑ Tank (2820) ��❑r+ Containers (2821) #of Containers: TA#: 1 Total Capacity: gallons Product Type: n (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TnA#: 2 Product Type: / Total Capacity: 2 b O gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (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: , t ❑ Tank (2820) ❑ Containers r(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: r7 5-'0 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed ,U,1 Date: Entered Date: �1 By Initial: " t{,b,0� By Initial: �Z '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. Nfl �un�U EHD 28-01 AST SURVEY FORM 08/12/08