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ti <br /> 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 Nam : /I <br /> ' PI 5 W G S-/%,r' 2 av T)y Page [ of <br /> Facility Address: ► City: Inspect' n D te: <br /> `� 33 - Al at- C i o 2FM <br /> FA#: IPR#: Program lement: <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 /> P-tank (2820) El Containers (2821) <br /> #of Containers:z2ii T : <br /> 1 Product Type: <br /> Total Capacity: �- �� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> al ank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 � Product Type: <br /> Total Capacity: 10gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (2820) 9Containers (2821) #of Containers: / TA#: <br /> 3Product Type: (/!i./�. r�o <br /> Total Capacity: > gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> C ,dnk (2820) /containers (2821) #of Containers: TA#: /��� q <br /> 4 Product Type: 0 <br /> �s <br /> Total Capacity. s 7_s _ gallons <br /> (per tank or cumulative _.tainers by product type) Install Date: <br /> D Tank (2820) Containers (2821) #of Containers: TAA <br /> #: <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: 2�-� gallons Total Capacity for Site: l ZZ gallons <br /> Comments: /!f 'Z Z <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: �Q -l_� By Initial: P12 <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 />