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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 />—UwU&1VU11U awidgC ldnK means a tank that has the capacity to stare 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 />Page If of <br />Facility ddrgss: _ <br />_I 9 <br />(/1I.�0 0. G(_ u[+ -?91 <br />-t�� <br />City: <br />Inspectio Date: <br />l �i <br />FA #: <br />--�/� � � ��� � <br />Program Eleme t: <br />X3Z <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum <br />21,320 gallons in tanks* and containers". <br />Complete one box for each tank or each cumulative <br />container product type. <br />❑ Tank (2820) ,0 Containers (2821) <br />#of Containers: <br />_� TA#: _PI–ol2p �3 <br />1Product <br />Total Capacity: j ZDC� gallons <br />Type: <br />rl 'e5'2.t -'WLD �I 6tE Y1° ' <br /> <br /> <br /> �� <br />❑ Tank (2820) ,ZContainers (2821) <br />#of Containers: <br />TA#: 19502/9 /' � <br />2 <br />Total Capacity: �� (� gallons <br />Product Type: <br />J ` s-e'u —W> , ,Ie tau .(p,� <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) -Containers (2821) <br />#of Containers: <br />TA#: <br />3 <br />Total Capacity: -2-500 gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />/El Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: 0,r,2 74D l ! (� <br />4 <br />Total Capacity: 2Srp gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />� <br />Tank (2820) El Containers (2821) <br />#of Containers: <br />TA#: g <br />5 <br />Total Capacity: gallons <br />Product Type: <br />&e,v`e::M-�pnLd Gj�ytQi�U�u� <br />_�i(� <br />(per tank or cumulative for containers by product type) <br />Install Date: <br /> <br />Total Capacity this Page: -5 Ci (� <br />gallons <br />Total Capacity for Site: i4lil D gallons <br />Comments: <br />e <br />EHD Inspector: <br />Q3 t t <br />TRe-viewed Date: <br />y Initial:t' <br />I ` <br />Entered Date: <br />By Initial: <br />*n....,,.__...._� _ <br />—UwU&1VU11U awidgC ldnK means a tank that has the capacity to stare 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 />