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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 of <br /> Facility Address: 9--,D City: Inspection Date: <br /> La <br /> FA#: PR#: Program Element: <br /> 00 L 6 �I-�v D 2.9--6 <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 /> El Tank (2820) Z-Contaaiin�ers (2821) #of Containers: �_ TA#:�5o2AD� <br /> 1 Product Type: `PT fJ1 <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#: Sb1l9DLP <br /> 2 Total Capacity: gallons Product Type: _(n1.,,,'oZ�a, <br /> (per tank or cumulative for containers by product type) � ,Install Date: <br /> ❑ Tank (2820) Z Containers (2821) #of Containers: TA#: LLA Lea 7 <br /> 3 SProduct Type: 4Vl r lwx <br /> <br /> <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: '3�0 gallons Total Capacity for Site: 0 gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: EntereDate: <br /> -�' 2•lQ(p By InitialuM„ tZ r3l`O By Initial: L <br /> "Aboveground 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 /> 09/12/08 AST SURVEY FORM <br />