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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 ,/ i'' %�� (_ � S'd ti/� Page / of I— Z Facility Address: it y inspection Date: FA#: 1,5763 - PR M Program Element: 05aCfle � 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) ❑ Containers (2821) #of Containers: TA#: DJ`I I q 1 � • f Total Capacity: ? �� gallons Product Type: (per tank or cumulative Or containers by product type) Install Date: 19'Tank (2820) ❑ Containers (2821) #of Containers: TA#: S"o2BO 2 Total Capacity: / l/iii gallons Product Type: ,1 2� j (per tank or cumulative for containers by product type) Install Date: ❑'Tank (2820) ❑ Containers (2821) #of Containers: TA#: D>SI g-a 3 � Product Type: Total Capacity: 1.�P � gallons (per tank or cumulative for containers by product type) Install Date: ' ❑ Tank (2820) R'Containers (2821) #of Containers: _� TA#: 4 r' Product Type: /-� 12df Total Capacity: � ,j• gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Ef Containers (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: /0 gallons Total Capacity for Site: Lf 0 6 gallons Comments: 1 ld2 0"j Id ------4 EHD Inspector: Reviewed Date: Entered Date: By Initial: k4.(lp•011 By Initial: �$ B Aboveground storage tank means a tank that has the capacity to store 55 gallons or more ol pe roleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08108