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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.sigov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Na e: <br /> e ( � b1'L Page Z of <br /> Facili Address: <br /> y ^' SY ot"e � oj to H by <br /> City: Inspection ate: <br /> > 1 <br /> FA#: —7 Ll—7 PR#: © Z Program Element: <br /> � 2 3 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks*and containers". <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: 9517'yIP <br /> 1 Product Type: TAn� r ¢ Q <br /> Total Capacity: Z SDb gallons yp ' I� i <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#:��q���7 <br /> 2 Total Capacity: 110 , (00 gallons Product Type: L (6 - \� h p 0✓Z-- <br /> (pertank orcumulativefor contai ersbyproducttype) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3Product Type: TAnV- t� (� — (ata I�,w, 0 <br /> Total Capacity: Z01 1 Z5 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: i ? ) <br /> 4 Product Type: TQNC I g CjA} 01 i� <br /> Total Capacity:�3D1 00(> gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: ,f TA#: 19517'` &0 <br /> 5 Product Type:TQA�L Fr I� - 6-f1n4A6L- <br /> Total Capacity: Q (200 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: ' 01 LICI gallons Total Capacity for Site: l � S gallons <br /> Comments: f <br /> EHD Spector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: / <br /> *Abovegr and 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 />