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SAN JOAQUIN COUNTY j 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�✓ J(`� �'�2 AIA /� �f✓/�'J age of Facility Address: ! City: Inspe tion a FA#: PR M ko ram Ele ent: 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. c� Ck�Tank (2820) ❑ Containers (2821) #of Containers: TA#: /9 !7 l 773 1 0 © Product Type: Total Capacity: �1 � gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: ��, 17 74D 2 Product Type: 0l' 1 Total Capacity: kk 0-D gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) P-Containers (2821) #of Containers: �_ TA#: b l 77T 3Product Type: �za::�zy l3�%"•.� �✓ Total Capacity: L) gallons (per tank or cumulativefo cr ontainers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4Total Capacity: Ll 11 gallons Product Type: S (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: ioqjo gallons Total Capacity for Site: 19 gallons Comments: EHD Inspector: Reviewed �I Date: Entered Date: By Initial: vll 1,1%(-0� By Initial: ( 4 `Aboveground storage tank means a tank that`-as 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