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�yC— SAN JOAQUIN COUNTY <br /> NVIRONMENTAL 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 /> PA C-1 kc Mq <br /> X1`1 r l j Page <br /> 5 � -lof <br /> Facility Address: — <br /> L- <br /> cty: ll2� zZ331 07FA# PR#: <br /> D/ D(_,j _ Program Element: <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#: <br /> 1 Total Capacity: 1 nig Product Type: I- ':}'( j( I-))' L <br /> p y: �" gallons <br /> (per tank or cumulative for oo teinersby product type) Install Date: t/ Nk�.lk.o" <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: gallons Product Type: N Z�l lib IIVA, 0/ L <br /> (per tank or cumulative for con ainers by product type) V�I t� <br /> Install Date: ho_ _ <br /> Ix Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: 3 -'S-L) gallons Product Type: <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: 2- TA#: <br /> 4 Total Capacity: [ I D gallons Product Type: US¢1) Oil <br /> (per tank or cumulative for containers by product type) Install Date: <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) <br /> Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: 6 gallons <br /> Comments: <br /> EHD Inspect Reviewed Date: Entered Date: <br /> u� By Initial. 'J.,+j 1_L.(.t By Initial. <br /> 'Aboveground torage 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 />