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t • SAN JOAQUIN COUNTY M <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: PA A tL, S+L1A"(3C TN Page I of Z <br /> Facility Address:30 2 8 il�U � City:^�� Inspe ion Date: <br /> r1 U\ <br /> FA#: PR#: Program Element: <br /> 053fj24 293 <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) O Containers (2821) #of Containers: TA#: z95/SFAIB(p <br /> 1 Total Capacity: S.S()( yWgallons Product Type: h9—Nib( reJ E 4� o <br /> (per tank or cumulative for containers by product type) Install Date: 61 1 I I 6 8 <br /> r <br /> Tank (2820) El Containers (2821) #of Containers: TA#: /-) (jR g 7 <br /> 2 Total Capacity: 6l3 gallons Product Type: j2fyA Orae/"' ,A� �L <br /> (per tank or cumulative for oontamO e by product type) <br /> Install Date: <br /> [Tank (2820) ❑ Containers (2821) #of Containers: TA#: ��l!?4 Cgs <br /> 3 Total Capacity: 00 gallons Product Type: M!a( U rA- L'' �$f0 l f� <br /> (per tank or cumulative for containers by product type) Install Date: L ( I 10 b <br /> El Tank C��iineTA#: <br /> errs: Z <br /> Tank (2820) Containers (2821) I <br /> 4 Product Type: (9 AYE b <br /> Total Capacity: �] b _gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) XContainers (2821) #of Containers: J_ TA#: <br /> 5Product Type: 2 b L-Iz, 'J l�ge--L <br /> Total Capacity: SS gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: I 6Z1 b gallons Total Capacity for Site: 2 '��0 gallons <br /> Comments: <br /> EHD Inspect r: Reviewed Date: Entered Date: <br /> 1c�2� By Initial: y� By Initial: <br /> -Abovegroun 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 />