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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: /U gg / <br /> IL AI N G J-) Page / of <br /> Facility Address: City: Inspectiop Date <br /> f� . la .� (� M �� / � �l $ 6� <br /> FA#: _ PR#: Prot EI a t: <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: � TA#: /9,S l -7 /S' <br /> 1 $ 7 <br /> Total Capacity: � ofl gallons 6T <br /> Product Type: AS <br /> (per tank or cumulative for containers by product type) Install Date: <br /> EY/Tank (2820) ❑ Containers (2821) #of Containers: TA#: /9`�i 17 7 (!!Z _ <br /> 2 Product Type: <br /> Total Capacity: �O-'b gallons <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: N6-1 `77a/2 <br /> 3 Product Type: ��C o <br /> Total Capacity: Sp-D gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 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 /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: f 5O 0 gallons Total Capacity for Site: /S'ale;f gallons <br /> Comments: I ,� <br /> Gkcr, J 1 <br /> EHD Inspector: Reviewed1 ' I Date: Entered Date: <br /> v By Initial: WA'" (}•teo��� By Initial: <br /> 1 c�?� <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 />