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SAN JOAQUIN COUNTY r. — ?NVIRONMENTAL HEALTH DEPARTMEN X00 East Main Street,Stockton,CA 95202-3025 ` Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: G Page � of Facility Address: City: Inspect' n Date: G>ri LS ST�� / a 8 FA#: PR#: Program Element: C) 3 3-0 6.572. 3 1 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 ank(2820) ontainers(2821) #of Containers: ` TA#: 06-1 ��0,2 Q- 250 gallons) Y>55 gallons and<250 gallons) I ��, Product Type: G Total Capacity: D O gallons (per tank or cumulative for c ntainers by product type) Install Date: P,-Tank(2820) ❑ Containers(2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Typ Total Ca ' gall s per tank or cumulative for containers by product type) Install Date: Gunk(2820) ❑ Containers(2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Tota l-C acity: Install Date: (per tank or cumulative for containers by product type) Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and 1250 gallons) Product Type: Totem apacitv:_—� ' gallons (per tank or cumulative for containers by product type)\1 I-- -mazzow. Install Date: ank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) =, 5 Product Type: Total Capacity: 1,-;2 D O gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: �a gallons Comments: EHD Inspector: Reviewedt TTBy ntered Date: C c By Initial: V Initial: EHD 28-01 v/ 01/16/08