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I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEA 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: GO o ,moi 7'-•---D C o/1/rAIA1CA� C- 0 Page of Facility Address: City: Inspectio Date -FA—#: � � /W � 3 9b PR#: D 517"R& Progi}am El e : �� 2Fs3 I Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2!1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product e. ❑ Tank (2820) E'�Contain <2 (2821) #of Containers: _ 3 TA#: B6 (>250 gallons) (>55 gallons and Q50 gallons) 1 Product Type: 1,f y Total Capacity: gallons �� L)c l (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ontainers (282 1) #Of Containers: TA#: (>250 gallons) (>55 gallons and<Z50 gallons) 2 Product Type: Total Capacity: `/ ga110ns (per tank or cumulative for containers by product type) Install Date: T Tank(2820) Containers (2821) #of Containers: TA#: >250 gallons) (>55 gallons and<250 gallons) o Product Type: ^ p Tp� 0/otal Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) `� " 21) #of Contai ers: � A#: 4 (>250 gallons) (> ga Ions2?00 gall Total Capacity: Product T e: p y gallon (per tank or cumulat- a for containers by product type) Install Date: ❑ Tank (2820) ontainers (2821) 5 #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) Total Capacity: gallons Product Type: (per tank or cumulative for containers by pro Install Date: Total Capacity this Page: s$Q gallons Total Capacity for Site: gallons Comments: 1� LEHDFspe-ctor: Reviewed 0 . f Z Date: Entered t) ! 01 By Initial: Date: 1��,-�t By Initial: ( n EHD 28-01 !/ 01/16/08