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SAN JOAQUIN COUNTY ^\ 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: _ ' G VT jy 6 - Page _,L_ of _ Z Facility Address:City: 10 5, 414 -ro Inspection Date: ,, FA #: �7 PR #: 6) 53 PrograYfi Element: Z_ Q Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks` and containers". Complete one box for each tank or each cumulative container product type. ❑' Tank (2820) ❑ Containers (2821) #of Containers: TA#: (g'212 1Product Total Capacity: Soo gallons Type: (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: 2Product D Tank (2820) ❑ Containers (2821) Total Capacity: � � � gallons Type: (per tank or cumulative for containers by product type) Install Date: El Tank (2820) L� Containers (2821) #of Containers: _ �� TA#: 3 Total Capacity: Z. Z /� gallons Product Type: / 0 (per tank or cumulative for containers by product type) Install Date: 22 Tank(2820) ❑ Containers (2821) #of Containers: ZAP#: �-} 4 e�--�X-� Product Type: Total Capacity: 3 gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) 2 -Containers (2821) #of Containers: _TA#: 5Product Type: Total Capacity: 1,12 gallons ` (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: `$ 3 C) gallons Total Capacity for Site: 3 gallons Comments: LA EHD Inspector:I! / L Reviewed Date: By Initial: ` , ��{-Q� Entered Date: By Initial: ry ."q "`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 -11