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0 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 Nam <br /> / 'q <br /> P,o S 0/ (, C J <br /> c> / ©G /i-- Page <br /> Page Of <br /> Facility Add-eess:Z. <br /> �� / �� 7-0,V <br /> `�V' ity: �_ Inspects n Dat <br /> AV ,yoeb)T 10/ FF 00 <br /> FA#: PR#:952 8 5 Propr�Element: <br /> Tank/Container Information Id9 7 <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 /> Y Tank (282m n rnntniners (2821) #of Containers: TA#: <br /> 1 Total gallons Capacity: �� � Product Type: <br /> (per tank or cumulative for cortfaroduct type)mers by `� <br /> ,y Install Date: <br /> Tank (2820) ❑ Sfltainers (2821) #of Containers: TA#: fJh ) 7S: <br /> 2 Total Capacity: � 'Z lel Product Type: 1,16 <br /> P Y / gallons / <br /> (periank orcumulative for containers by product type) Install Date: Zi(XVZII <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: __21�5/!?& 77 <br /> 3 Product Type: I,Wj.V_(i(,Wj �P�t <br /> , l <br /> Total Capacity: � — gallons f�e <br /> (per tank or cumulative for�containers by product type) Install Date: "� 1� ,��(.? , <br /> ,Z Tank (2820) El Containers (2821) #of Containers: TA#: V (ri <br /> 4 Total Capacity: gallons Product Type: 6L)'/1 I LIV4 �� D <br /> (per tank or cumulative for containers by product type) Install Date: "2,';o tU <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: 5-01 000 gallons Total Capacity for Site: 5o , o c)() gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Dat <br /> By Initial: (t.�-I)� By Initial: <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 AST SURVEY FORM <br /> 09/12/08 <br />