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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: GZ/j'77Lu �-z�, 1}'JC . Page of Facility Address: City: Inspects n Date: FA#: nPR#: /- Progr m Element: CP 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. X Tank (2820) ❑ Containers (2821) *of Containers: TA#: 1 Total Capacity: f 5C 0 gallons Product Type: 74r� G�a� (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) L?(Containers (2821) #of Containers: TA#: u 3 5� 2 Total Capacity: �Q gallons Product Type: �ZLd l.(�C 4121 (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: ❑ Tank (2820) ❑ 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: � �� gallons Total Capacity for Site: gallons Comments: EHD Inspect _ Reviewed (� v Dater-, I{ , i Entered Date: TBy Initial: \�J By Initial: *Aboveg(o—unq itorage tank means a tank that has the capacity to store 55 gallons or more of petroleum. "Contain eans a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08