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e SAN JOAQUIN COUNTY •, / V U t) 4/ <br /> ENVIRONMENTAL <br /> ENVIRONMENTAL HEALTH DEPARTMENI <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: p <br /> 1 '� L +4'�\q1 J d TL Page i— of <br /> Facility Address: I / City: Inspe ion Date: <br /> 302 V , sc,lGFzso.J <br /> FA#: PR#: Program Element: <br /> 05'?L 2 1? 3 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and container"s" <br /> . <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) <br /> El (2821) #of Containers: TA#: F/51-Fq'3L <br /> 1 �r�o� 00o J Product Type: 1)2-r1�reA E ft,M o L <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) /l I I O C9 <br /> Install Date: <br /> Tank (2820) ❑ Container (2821) #of Containers: TA#: g 7 <br /> 2 suo, o0o� Product Type: �e � U �A� 1 <br /> Total Capacity: gallons nn <br /> per tank or cumulative for containers by product type) Install Date: <br /> [Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: 00 gallons Product Type: L D`4 U rk(-L. <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) !}Containers (2821) #f Cpnta iners: //x TA#: g g <br /> 4 Product Type: U Aj 4 D I . R --, <br /> Total Capacity: �$ gallons <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ❑ Tank (2820) XContainers (2821) *of Containers: ✓ TA#: —( <br /> 5 D Product Type: 2 b ulR 0 %e-S� <br /> Total Capacity: �—�- gallons <br /> (per tank or cumulative for containers bgroduct typeL Install Date: f7 � L <br /> Total Capacity this Page: tI—�J C— gallons Total Capacity for Site: gallons <br /> Comments: <br /> Gita Q l S is <br /> * tl sfI t5 0 5� a LLor� drums o <br /> r <br /> fh e <br /> I <br /> EHD Inspect Reviewed Date: Entered Dale: <br /> By Initial: �(/.Q°jBy Initial: <br /> *Abovegrounj 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 <br /> 0912108 AST SURVEY FORM <br />