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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: <br /> Ar QN h 9/1ll L . Page of <br /> Facility Addres : city: Inst( n Da <br /> 00 �r G rLQ( <br /> FA M 7PRR Program Element: <br /> Ll <br /> � ? 3l <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 11,320 gallons in tanks`and containers". <br /> Complete one box for each tank or each cumulative container product type. <br /> ❑ Tank (2820) XContainers (2821) #of Containers: TA#: <br /> 1 Total Capacity: 7. gallons P-7r d/u' A-,?-ct e: 6zj 'GJ r�1G�fz CS/Z <br /> (per tank or cumulative for containers by `� ° i46$ I i r n 1 ��� <br /> Install Date: i4a 121,111 <br /> ❑ Tank (2820) Xcontainers (2821) #of Containers: TA#: BSI q/P,� <br /> 2 Total Capacity: TS Product Type: W-eA E �/`4ryS ,'� PtWh <br /> p y: gallons poWn 1-P+'wl Kr <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 1 �f Tank (2820) El Containers (2821) #of Containers: JJ TA#: <br /> 3 I Total Capacity: ,� gallons Product Type: �M�(A,t GI U�t:G m <br /> (per tank or cumulative for containers by product type) ow ix <br /> Install Date: <br /> -ff Tank (2820) f2-Containers (2821) #of Containers: �_ TA#: f r,,2 F23D <br /> 4 TCapacity: Product Type: (�(l�5}2 (T <br /> Total Ca <br /> p y: gallons `h s <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (pertank or cumulative for containers by producttype) Install Date: <br /> Total Capacity this Page: L((�C gallons Total Capacity for Site: 2353 gallons <br /> Comments: <br /> A C 'J 1 <br /> EH spectoi: 'RiReviewed i^ Date; Entered Date <br /> By Initial: .� By Initial: <br /> "Above sound storage tank means a tank that has the capacity to store 55 gallons or more o petroleum. <br /> "*Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />