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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 Nam . G r c, 136; 1111c-, Page --,/ of Facility Address: ci Inspection Dat : L / �- 07 FA#: PR#: Prog am Element: 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#: 1 Total Capacity: /0 00 gallons Product Type: � �' � (per tank or cumulative for containers by product type) Install Date: Tank (2820) ElContainers (2821) #of Containers: TA#: _e 5l 2 2 Product Type: / Q Total Capacity: Z O 00 gallons � (per tank or cumulative for containers by product type) Install Date: CZYTank (2820) ❑ Containers (2821) #of Containers: TA#: D5S17F3Lo 3 Product Type: Total Capacity: .Sd 0 gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) &6ontainers (2821) #of Containers: TA#: /911 — - - R-& 4 Total Capacity: // D gallons Product Type: 4//71,4 O/ t✓ (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) [y Containers (2821) #of Containers: TA#: 5 , Product Type: Total Capacity: / 0 gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Z'0 gallons I Total Capacity for Site: '� v gallons Comments: 3 EHD Inspector: Reviewed Date: Entered Date: By Initial: ra C_ d� By Initial: 1O *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