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0 SAN JOAQUIN COUNTY 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: ��,p�� <br /> " "� {, U (� Page of <br /> Facility Address: <br /> fVY <br /> City: 51 "' Inspection DDate: M <br /> FA#: PR#: L V <br /> 61 :11 J5/ Prog��l 2- <br /> Tank/Container Information C_ <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 roduct t e. <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: DS/q/v7o't <br /> 1 Total Capacity: S k Product Type: � <br /> gallons <br /> (per tank or cumulative for containers by product type) oC,gP tbVt <br /> Install Date: tSF�tnSer <br /> k7 Tank (2820) ❑ Containers (2821) #of Containers: e TA#: 7-!5 <br /> 2 Total Capacity: SI/— gallons Product Type: L <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: A,SI'?Ze '7 <br /> 3 Total Capacity: gallons C-cam Product Type: Gl aS V, <br /> —Ap-- <br /> (per tank or cumulative for cant�alne by pro—_tluct type) Install Date: <br /> )1 Tank (2820) ❑ Containers (2821) #of Containers: TA#: �� _ <br /> 4 Total Capacity: �j }(� gallons Product Type: �•( � �`, ) <br /> (per tank or cumulative for containers by product type) Install Date: <br /> .!'Tank (2820) ❑ Containers (2821) #of Containers: TA#: BEI�Z4 -7 4z <br /> 5 i r`7 J <br /> Total Capacity: kFM gallons Product Type: Ti7{ 1 { I Uic1 C-S I <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: I _ gallons <br /> Comments: <br /> ftx-'sI <br /> 5zAL 'vt ' de In o <br /> EHD Inspector: 0 61 T7 <br /> Reviewed Date: Entered Date: <br /> By Initial: VA� G�-4-to By Initial: 7 <br /> 'Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> "Container means a storage device designed to be moved when full. <br /> EHO 28-01 <br /> 00/12/08 AST SURVEY FORM <br />