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SAN JOAQUIN COUNTY *ENVIRONMENTAL HEALTH DEPARTM �• 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 T/ / � OF �g A U -Y Page I-- of Facility Address: City: Inspection Date: FA #: PR #: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum > 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. EA/Tank(2820) ❑ Containers (2821) #of Containers: TA#: 05-1-7D 7�5- (>250 gallons) (>55 gallons and <250 gallons) 1 Product Type: Total Capacity: / 0 O d d gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) E� Containers (2821) #of Containers: 'y TA#: / 7D (>250 gallons) (>55 gallons and <250 gallons) 2 Product Type: 9/ Total Capacity: //0 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA #: Ah 17,0 3 (>250 gallons) (>55 gallons and <250 gallons) Total Capacity: / D o a gallons Product Type: Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 4 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: I / 0 gallons FTotal Capacity for Site: gallons Comments: EHD Inspector: Reviewed By Initial: Date: Entered Date: By Initial: G1��// EHD 28-01 01/16/08