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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 FOPM Facility Name: G,��'o L>C> Page __� _ of �— Facility Address: City: Inspectioz ate: �Z FA #: PR #: /o Program leme4 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#: C)15/4,3-7 / 1 Total Capacity: gallons Product Type:_ (per tank or cumulative for containers by product type) Install Date: Xi Tank (2820) ❑ Containers (2821) #of Containers: TA#: V516 19-7 -� 2Product Total Capacity: (�So gallons Type: L-14Q4e- c> / (per tank or cumulative for containers by product type) Install Date: ,Tank (2820) ❑ Containers (2821) #of Containers: TA#: C )f / 6- $73 3 qft Total Capacity: '3610 gallons Product Type: 5L. ' - zo Of`/ (per tank or cumulative for containers by product type) Install Date: Fr' Tank (2820) ❑ Containers (2821) #of Containers: TA#: 05 Wa-''i + 4 Total Capacity: ` 7'L�-0 gallons Product Type: A%'F (per tank or cumulative for containers by product type) Install Date: v f Tank (2820) ❑ Containers (2821) #of Contain rs: TA#: S(�25� 5 Total Capacity: -Z-,OO gallons Product ype: 5w - c7 (per tank or cumulative for containers by product type) Install Date: �_ Mkw T-/+ Total Capacity this Page: O gallons Total Capacity for Site: �� gallons Comments: �y IF in a OH 091' AU ? nn / EHD Ins ctor: 5 - Reviewed IBy Initial: Date: �L •t Entered Dat7 e: By Initial: �- E - rn i zfnrnqn f-1, 4-1, IL- �-- . v- - �• �•� ua� .W,... a LaIrn Ll 1aL nds uie capacity to store 55 gallons or more of petroleum. ( ` "` ontainer means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM