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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 /> Facilit Name: p <br /> l LL Page —L of <br /> Facility/+ddress: City: <br /> Ib �� F�'t/1G1.� Inspection Date: <br /> PR#' Program Element: <br /> bl3 es s9� n3I <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 t e. <br /> Tank (2820) ❑ Containers (2821) *of Containers: TA#: ay�� <br /> 1 Product Type: -144U <br /> Total Capacity: �_gallons 6 _ <br /> (per tank or cumulative for containers by product type) Install Date: (6�'rA s <br /> ❑ Tank (2820) containers (2821) #of Containers: TA#: 0,5a2 <br /> 2 Total Capacity: _gallons Product Type: <br /> (per tank or cumulative for wniainers by product type) Install Date: e�s49 <br /> ❑ Tank (2820) FzrContainers (2821) *of Containers: Fi—� TA#: DD9� <br /> 3 Total Capacity: 2:��J)—gallons Product Type: Q'�) 4d awl 4�f ,_ <br /> (per tank or cumulative for containers by product type) Install Date: o , back #-eAw <br /> ❑ Tank (2820) J2'Containers (2821) #of Containers: �_ TA#: 12�aDD� - <br /> 4 Total Capacity: a SD gallons Product Type: rc)) <br /> (per tank or cumulative Tor containers by pro—duct type) Install Date: <br /> ,,❑'Tank (2820) ❑ Containers (2821) #of Containers: TA#: j9, r <br /> 5 Total Capacity: gallons Product Type: f �S — <br /> (pertankorcumulativeforcontain type) Install Date: (,bb-f'1�r. <br /> Total Capacity this Page: gallons Total Capacity for Site: <br /> Comments: gallons <br /> EHD Inspector: Reviewed Dale: Entered <br /> Date: <br /> 0[- (�'�� By Initial: l Z� I1 By Initial <br /> `Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of a roleum. o� <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />