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.� so 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: /l W l2 G / LP Page / of Facility Address: City: Insp7P� 5 - D /vim r J FA#: � PR#: � Program�emen o &6'v q � 3 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: TA#: /W/g411o2. 1 1 Product Total Capacity: /Q C/00 gallons Type: (per tank or cumulative for containers by product type) Install Date: /Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: ,SCR"/ Total Capacity: "p r,0 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: /9 SI g 3 Total Capacity: 5-0() gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ETank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: �4 f Total Capacity: ,F 0 0 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: 16 , 00 (l gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered DatV02 By Initial: S jt _0 By Initial: &_ *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