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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.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> o ' r L�t, 4 � iG J�-6� Page of <br /> Facility Address: City: Inspection Date: <br /> s ��� 7--z -6 9 <br /> FA M: PR 9: Program Ele nt: <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 /> #of Containers: TA#: -7� <br /> Tank (2820) ❑ Containers (2821) <br /> 1Product Type: t tjdy� <br /> Total Capacity: 44006 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: 196-)G( 176- <br /> 2 6 ,n Product Type: �rAs 97 <br /> Total Capacity: / C�VTV gallons <br /> (per tank or cumulative for coont/in'ers by product type) Install Date: <br /> El Tank (2820) Ly C`ontainers (2821) #of Containers: 3 TA#: D � ) l7 �P <br /> 3 Total Capacity: / 6� gallons Product Type: _(9 TJn I'L 0/U <br /> (per lank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: TA#: &C6-( 1 -7 <br /> Total Capacity: �gallons / 7 <br /> 4 Product Type: I�WAR) I OIL <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ontainers (2821) #of Containers: TA#: 8,5/1q 17 <br /> 5 Product Type: /�rOt1�7F dly <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: S`L galions7 Total Capacity for Site: r gallons <br /> Comments: yGL <br /> b14 <br /> S �TTG <br /> EHD In ector: " Reviewed Date: Entered Date <br /> By Initial: q_1j_� By Initial: l <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 /> AST SURVEY FORM <br /> EHD 28-01 <br /> 09/12/08 <br />