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x _ SAN JOAQUIN COUNTY YNVIRONMENTAL 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: Goo OUT �f/�S7- Page � of_ Facility Address: City: Inspeotio Dr�p 2 - . U� 7 � FA#: PR#: Program Element: 50 8-22� 1 DS; Tank/Container Information Complete r 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. VTank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: �� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: i 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: f El Tank (2820) ElContainers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) I nsta Il Date: El Tank (2820) El Containers (2821) #°f Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Inst.alI Date: ❑ Tank (2820) ❑ Containers (2821) #of°Containers: TA#: 6 Total Capacity: gallons Product Type: (per tank or cumulative far containers by product type) Install Date: Total Capacity this Page: si7--� gallons Total Capacity for Site: Cl'D gallons Comments: AIV OeA 07-0 EHD Inspector: Reviewed Date: =Entered Date: By Initial: �,-ty Initial:T dr 0 *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 l AST SURVEY FORM 09/12/08