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F <br /> .Nxi. 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.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> � /Lp IV F LC 0�1 7'�� ,% r1+ C —Gl, Page of <br /> Facility Address: City: Inspectio Date: <br /> Z� '�Q W� &A 09f4<1 ��� L% roo7- 7/02 <br /> FA#: PR#: <br /> 0� Program Element: <br /> 6 2 <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#: •_ <br /> 1 Product Type: <br /> Total Capacity: ._-- 'L/ 0 gallons - • --•-• <br /> (per tank or cumulative for containers by product type) Install Date: <br /> i <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Product Type: <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 /> 3 Total Capacity: Product Type: <br /> p y: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: Product Type: <br /> p y: � gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site; gallons <br /> Comments: <br /> 2,6 <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: 14 By Initial: <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 /> END 28-01 AST SURVEY FORM <br /> 09/12/08 <br />