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SAN JOAQUIN COUNTY <br /> •ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> / al' Page �-_" of <br /> Facility Address: City: Inspec to Date: <br /> loCuo S . <br /> FA#: PR#: Program Element: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks`and containers". <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) ❑ Containers (2821) "of Containers: TA#: A�5'Aj,3QI <br /> 1 Product Type: �/ / CIiY C�L(f1ZF4 <br /> Total Capacity: � C n gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 1z Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2Product Type:& (�/�� <br /> Total Capacity: CP C-) O gallons <br /> (per tank or cumulative for containers byproduct type) Install Date: <br /> ❑ Tank (2820) j<Containers (2821) #of Containers: / TA#: e,6--4,9, <br /> 3 Total Capacity: GD GD gallons Product Type: (,ISef d 017 <br /> (per tank or cumulative for containers byproduct type) <br /> Install Date: / , <br /> El Tank (2820) Containers (2821) #of Containers: _� TA#: 4A5,///J`3V� <br /> 4Product Type: uhC) 07 ( w /—C- <br /> (per <br /> —C F3s� <br /> Total Capacity: �� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: O gallons Total Capacity for Site: "(fi1� gallons <br /> Comments: <br /> EHD I pector. Reviewed / Date: ^ „ Entered Date: <br /> By Initial: <br /> *AbpVe0r6und storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> "C finer means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />