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SAN JOAQUIN COUNTY 2 Q� 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 LL! 5 Page of i -/ G �_ Facility Address: City: Inspectionrate: -2-o 5 ,� FA #: PR M Program EI z 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. 1--l'ank (2820) ❑ Containers (2821) #of Containers: TA#: 1Product Total Capacity: � eV gallons Type: /-2x— (per tank or cumulative for containers by product type) Install Date: 2 Tank (2820) 11Containers (2821) #of Containers: TA#: 2 �,.b Product Type: Total Capacity: 3 gallons (per tank or cumulative for containers by product type) Install Date: 112/Tank(2820) ❑ Containers (2821) #of Containers: TA#: 3 r Product Type: Total Capacity: � � gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) 11 Containers (2821) #of Containers: TA#: 22 4 �- Product Type: /rA S �� Total Capacity: 7 t0 gallons (per tank or cumulative for containers' by product type) Install Date: [Tank (2820) ElContainers (2821) #of Containers: TA#: r. --A 5 Product Type: Total Capacity: ) gallons (per tank or cumulative for con ainers by product type) Install Date: Total Capacity this Page: Z U 0 gallons Total Capacity for Site: Z Q D gallons Comments: EHD Inspector: Reviewed Date: By Initial: Loi o•D� Entered Date: By Initial: jq b7 *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