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r 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: g a o r -5 Pae of Facility Address: � J�j City: Inspection Date: 1510 W- 5 ZA f FA#: PR M Program Elemea+•• — I a Zg30 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: A#: nf,�q-I Sq rjlQ 1 Product Type: Total Capacity: (� gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: -F TA#: 2 Product Type: � � Total Capacity: 0 gallons (per tank or cumulative for con finers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by ers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Pag / t� r � J?0 gallons Total Capacity for Sit( gallons Comments: Civ ✓lis FAA CVY� L T ivy off-5 EHD Inspector: Reviewed \ Date: Entered Date: By Initial: `, J CC.l'>, 0 By Initial: �� 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 AST SURVEY FORM 09/12/08