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s 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 /> /y � IV �0/✓TGPage of <br /> Facility Address: Inspect n Da e:6 <br /> Ti( 6.411WAIL r%,-6 �r 7� <br /> FA#: PR#: 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 /> Ultank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Total Capacity: Jr gallons Product Type: <br /> (per tank or cumulative for contaiers by product type) Install Date: <br /> El Tank (2820) 2--containers (2821) #of Containers: TA#: <br /> 2Product Type: ,/�dTa17- U <br /> Total Capacity: gallons <br /> (per tank or cumulative for6mtamers by product type) Install Date: <br /> ❑ Tank (2820) e/C/ontainpirs (2821) <br /> #of Containers: TA#: <br /> 3 Total Capacity: � Lti/ <br /> J _ V gallons Product Type: QST� <br /> (per tank or cumulative for containers by product type) Install Date: k <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (pertank orcumulative 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) Install Date: _ <br /> Total Capacity this Pap, gallons Total Capacity for Sir gallons <br /> Comments: <br /> C 13 Zo OU IJP <br /> EHD Inspector: / Reviewed 1 Date: Entered Date: <br /> �.� - _ By Initial: V j.AV.v�j 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 />