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- F . SAN JOAQUIN COUNTY L 'NVIRONMENTAL HEALTH DEPARTMENT ew East Main Street, Stockton,CA-95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 'Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: - Al A A/ - G i 1w L-G W 7i7 Page � of Facility Address City: Inspection Date: FA#: PR#: Program Element: eQ 12 Tank/Container InforM-ation Co sles W1 cu o ound storage of petroleum z1320 gallons in tanks and containers over 55 gallons. Complete one bo 6r,,pach tank or each cumulative con e. Tank(2820) El-Containers (2821) #0 ntainers: T (>250 gallons) (�55 gallons and 450 gallons) 1 Product Type: Total Capaci y: gallons (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and 450 gallons) 2 Product Type:, Total Capacity: gallons (per tank or cumulative for containers by product type). Install Date' ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and 450 gallons) 3 Product Type: . Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and 450 gallons) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date' 3 ❑ Tank(2820) '❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 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: 3 gallons Comments: EHD Inspector: Reviewed I Date: Entered Date: i C24By initial: �N CI-`��j• By InIx EHD 28-01 7 01/16/08