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SAN JOAQUIN COUNTY ...i <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 /> Facilitye: <br /> Namn <br /> A1 <br /> MDU IO b IL0r1 Cd, �� &S Page � of—L— <br /> Facility Address: City: Impction Date: <br /> 2L1 2"( Gly V ie�l �SfoGlL�a► J /Y a <br /> FA#: PR M Pr gram Element: <br /> l ( D c-f 6 O 28 "l <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: <br /> 1 _ TA#: <br /> Product Type: NAS <br /> of ZTotal Capacity: � <br /> (per tank or cumulative for containers by product type) Install Date: U K+K:A rtM <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank orcumulative for containers by prooucltype) 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: rao gallons Total Capacity for Site: CJ gallons <br /> Comments: 0/'Z— o l )[J\ &04-L- <br /> EHD Ins actor: Reviewed Date: Entered Date: <br /> By Initial: (, th. J By Initial: <br /> bovegr and storage to k 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 <br /> /08 <br /> 09/12/08 AST SURVEY FORM <br />