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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: �J v C H GIgNQ A 11 / , Page of Rf/G Address: City: Inspecti n Date- atFAFacility FA#: 49 PR #: Pro&ao Element: 0 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. ank (2820) ElContainers (2821) #of Containers: TA#: 1 Product Type: Total Capacity: l o &9 � gallons (per tank or cumulative for containers by product type) Install Date: Ik' Tank #of Containers: TA#: ❑ Containers (2820) (2821) 2Product Total Capacity: ,l'd-f� gallons Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (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: % j �� gallons Total Capacity for Site: 0 d gallons Comments: EHD Inspector: A /! V Reviewed Date:Entered By Initial: '1.31- Date: By Initial: O *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