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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: <br /> Page -3 of <br /> Facility Address: City[: Insliection ate: <br /> FA <br /> 2 -7q^ PR#: Program Element: <br /> r b 2 -7 q -7 2 3 <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 (2821) #of Containers: TA#: 4517YIZ <br /> 1 4q ?5, Product Type: AnI L Zo — &A�o (�^ GI I oA <br /> Total Capacity: gallons <br /> (pertank or cumulative for containers by producttype) Install Date: I� <br /> 9Tank (2820) ❑ #of Containers: TA#: <br /> Containers (2821) � c7 <br /> 2 -J l 7 /9(p Product Type:-rAny <br /> Total Capacity: galrons <br /> (per tank or cumulative for contai ers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) *of Containers: TA#: 19 a DW,3$ <br /> 3 Product Type: T�(� ## ;-1 <br /> Total Capacity: 2,21 8, 52D gallons <br /> (per tank or cumulative for containers by product type) �loO 3 <br /> Install Date: O <br /> �*Tank (2820) ❑ Containers (2821) #of Containers: TA#: zEJ-5RN4-s3 <br /> 4 Total Capacity: S-, 4C) 0gallonsProduct Type: /�2 /G #4-7 — <br /> (per tank or cumulative for containers by product type) Install Date: /qq(g <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: - �jij-- 91111s Total Capacity for Site: 17 —gallons <br /> Comments: 3) to 4 , y g U g g -1 q 9 g <br /> GCS n L4 �(V <br /> a <br /> EHD I ctor: Reviewed �" ,p Dater 4 Entered Dater <br /> By Initial: �� jj', I t By Initial: /B rla <br /> bovegrou storage tank means a tank that has the capacity to store 55 gallons or more it petroleum. �C <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />