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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: <br /> A 13.4RoAl I Page 4— of)/- <br /> Facility AddrcZ �� - // / p Cir: ^O Inspection;a O <br /> FA#: <br /> PR N: L p Program Element. <br /> Oo 30 <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 /> 91 Tank (2820) 11Containers (2821) #of Containers: TpA#: d'Sl ?/9'7 <br /> 1 Product Type: &A S d 7 <br /> Total Capacity: $ 00 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> l�Tank (2820) 1:1 Containers (2821) #of Containers: TA#: /0 1-770 g <br /> 2 Product Type: [A <br /> Total Capacity: S0 0 gallons <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ank (2820) ❑ Containers (2821) #of Containers: TAM O J 17709 <br /> 3Product Type: 0� <br /> Total Capacity: J�_gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> &'Tank (2820) ❑ Containers (2821) #of Containers: TqqA#: <br /> 4 Product Type: .t <br /> Total Capacity: G d 0gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ®'Tank (2820) O Containers (2821) #of Containers: TA#: X9,51-77 l 1 <br /> 5 Total Capacity: /D 0Q D gallons Product Type: Olt <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 2,1 S00 gallons Total Capacity for Site: gallons <br /> Comments: Z D C 3 r G D <br /> EHD Inspector: r Reviewed Date: -/ Entered Date: <br /> By Initial: <br /> VIA 4-D'b By Initial:kf <br /> 'Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. O <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST S <br /> 09/12/08 <br />