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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 Page - of Facility Address: City: Inspection Date: FA #: PR Al: OtI3L�30 Program Element: 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#:�5/ g'7�s2 1"b0 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: CYTank (2820) ❑ Containers (2821) #of Containers: TA#: &A;) F571 a 2 Product Total Capacity:/ 0 4 '�q gallons Type: (per tank or cumulative for containers by product type) Install Date: #of Containers: _ TA#: ❑ Tank (2820) eContainers (2821) 3 Total Capacity: Z„7- v gallons Product Type: o (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑Containers (2821) #of Containers: 4 �� Product Type: Total Capacity: 3 gallons (per tank or cumulative for containers by product type) Install Date: El Tank(2820) 2-61ontainers (2821) #of Containers: 7A#: -Z 5 Total Capacity: '/ / 0 gallons Product Type: 444 (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 1 3 b gallons Total Capacity for Site: 3 gallons Comments: L% /' 022 k X EHD Inspector: > Reviewed Date: By Initial:ypl� Entered Date: By Initial: 07 D *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleu . "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08