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SAN JOAQUIN COUNTY r ` 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 r- C / L s-APIPAA !io U) 6��-%e R Page / of " Facility Address: City: � 6 8,r-- Inspection Date: o X S o /I/ FA PR #: Program Elqnant-1 od3O o x((33 // Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2-1,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. Imo' I ank (2820) ❑ Containers (2821) #of Containers: TA#: 1 � Product Type:--C-?—�/ Total Capacity: �gallons (per tank or cumulative for containers by product type) Install Date: ET" -Tank (2820) ❑Containers (2821) #of Containers: TA#7 2 -, O Product Type: � Total Capacity: .S � gallons (per tank or cumulative for containers by product type) Install Date: Tk (2820) El (2821) #of Containers: �A#: an 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: vTA#: 4 pB,� / Product Type: /21 Q Total Capacity: gallons / (per tank or cumulative for containers by product type) Install Date: �— Tank (2820) El Containers (2821) #of Containers: TAp#: c� 5Product Type: Total Capacity: S^ gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Pagg. V Q gallons Total Capacity for Site: Z 6 G� gallons Comments: C ' `, DIS P, fi s Ze,, S� 0� V EHD Inspector: Reviewed ` Date: By Initial: \ A,�J a_'��, � Entered Date: By Initial: /Oz *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 09/12/08