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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 /> Facility Name: ,11 r� �a,.� <br /> r—tj/'j r�C, 1 - /Z I,S %NCI Page of <br /> Facility Address: N <br /> city: Inspection D e: <br /> �3 iz�g o � <br /> FA M / 700KPR#: Program Element: <br /> 233 O <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 11,320 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#: 6pYz 76z <br /> 1U Malo /t- O G <br /> Total Capacity: /IF �O gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> SL�Bnk (2820) ❑ Containers (2821) #of Containers: TA#: 19552 -17 Al <br /> 2 Total Capacity: >0 Ogallons Product Type: /7//17X A 6i/G ©i <br /> (pert tank or cumulative for containers by product type) Install Date: <br /> 3 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 6�S1 '7 72f7 <br /> 3 Product Typ (2 <br /> Total Capacity: /l3 0 O O gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: -7 7,!Lf <br /> 4 Product Type: n <br /> Total Capacity: �0 (4) D gallons r <br /> (per tank or cumulative for containers by product type) Install Date: <br /> )µ] Tank (2820) El Containers (2821) <br /> #of Containers: TA#: �Q�J 772r/ <br /> 5c, .� Product Type: /iii.^� ✓ � Ly ' <br /> Total Capacity: .S gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: / gallons <br /> Comments: <br /> 6 i oyc1 etch 0^" <br /> H1iAlr QEG lIE <br /> EHD Inspector: //// Reviewed ` � _11 Date: Entered Date: <br /> �' 6 EBy Initial: 4f 4- vrclo 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 />