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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: /,J G Page _� of Facility Ad�l66ress:� � �. Co /� City: Inspection Date: x 4( - FA#: PR#: Program Elemen : Z- 5�_r I g 5 �Z_ g '36 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks*and containers*". Complete one box for each tank or each cumulative container product type. 19" ank (2820) ❑ Containers (2821) #of Containers: TAo#: 1 Total Capacity: �0 69 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 0-fa-nk (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: e, gallons Product Type: (per tank or cumulative for containers by product type) Install Date: LrYTank (2820) ❑ Containers (2821) #of Containers: TA#: ASI'6/97"3' 3 Product Type: 19--0, Total Capacity: 3'Sro gallons (per tank or cumulative for containers by product type) Install Date: O Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: Z O gallons (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: i Jr" a gallons Total Capacity for Site: /j—j-0 gallons Comments: EHD Inspector: C6 Reviewed Date: Entered Date: By Initial: �ka b 0� By Initial: 4 *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