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SAN JOAQUIN COUNTY 40 <br /> WNVIRONMENTAL 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 /> V u 4., 9 Page of <br /> FacilityAddress: City: Inspection ate: <br /> 3tf2h �&G M i z s�o� <br /> FA#: R#:Ds— �� 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 ai �gallons. (2621) #of Containers: TA#: r)f I C(7fe <br /> 1 Product Type: O 1Z <br /> Total Capacity: *y" S= <br /> (per tank or cumulative for containers by product type) Install Date: ()N I(A#1" <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: � <br /> 2 Total Capacity: 'Z �7 �Q gallons Product Type: Niel, �j(3h Ne`" A.*zAr-- <br /> (per tank or cumulative for containers by producttype) Install Date: U7V(Ltir►•--t <br /> ❑ Tank (2820) Containers (2821) #of Containers: TA#: 46-19573 <br /> 3Product Type: RyV j <br /> Total Capacity: ��gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) I Containers (2821) #of Containers: TA#: 5,,4;-j a5'�T_ <br /> 4 Total Capacity: gallons Product Type: 67eer LUlae, S c <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) )4 Containers (2821) #of Containers: TA#: 4C, (q,ri 2 D <br /> 5 Total Capacity: __gallons Product Type: S\'ell c pm <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: Q gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Apector.. Reviewed Date: Entered Date: <br /> ey Initial: 'lli AV 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 /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />