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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: IV /3 GG14 ,r—T7 —» Page of Facility Address: City: % G Inspectio Dat �f�3 0 6 y i47 A G IJ FA #: o s g PR M D -�3D Program Element: z 3D 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#: NCL) 1Product Total Capacity: 5 0 gallons Type: A (per tank or cumulative for containers by product type) Install Date: #of Containers: TAt#:Oc!3 I qr 7 Tank ❑ Containers (2820) (2821) 2Product � G Q Type: C'r� S 2S l Total Capacity: gallons Zper tank or cumulative for containers by product type) Install Date: 1 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: 5 g allons Product Type:% o (per tank or cumulative for containers by product type) Install Date: 2 Tank (2820) ❑ Containers (2821) #of Containers: -T 4 Product Type: Total Capacity: " gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: � Total Capacity: (" gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: �� gallons Total Capacity for Site: ZZ� gallons Comments: EHD Inspector: �i Reviewed Date: 0 ,p� By Initial: � ` " ` Entered Date: By Initial: /,p kT I Pf Le *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