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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: u <br /> Page_ of <br /> Facil' A e5•s/, <br /> v� ^ � /�/may- �� Inspect.on Dat <br /> FA M. r^ / v 1 /v" ]R# q ob6 3 1 t, Pr�raj El no <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 Droduct tvDe. <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: /95'19��Qy <br /> 1 Total Capacity: _ Product Type: �)l� 9QSGC� <br /> gallons <br /> y <br /> (per tankor cumulative for containers by product type) Install Date: Ut44q `-\. <br /> lk Tank (2820) ❑ Containers (2821) #of Containers: TA#: dr^J (gtS4� <br /> 2 Product Type: W*4j -1 , <br /> Total Capacity: `�(3u gallons <br /> (per tank or cumulative for containers by product type) Install Date: UN)L" <br /> Tank (2820) ❑.Containers (2821) #of Containers: TA#: iJ<�i lq(P <br /> 3 Total Capacity: tyallons Product Type: IAJA , ZLi9/�A)0,1t_ <br /> (per tank or cumulative for contam type) Install Date: V N n r <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5,6-) Q <br /> 4 Total Capacity: Ob gallons Product Type; IJOw A40 li a.()— <br /> (per tank or cumulative for containers by product type) Install Date: W V-"11— <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: `( Product Type: 6d <br /> (per tank or cumulative for c main.,,by product type) Install Date: UU <br /> Total Capacity this Page: gallona Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspect Reviewed Date: Entered <br /> UA r✓ By Initial: Date: <br /> By Initial: <br /> 'Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. L <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/17/08 AST SURVEY FORM <br />