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SAN JOAQUIN COUNTY <br /> ZNVIRONMENTAL 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 COAAtj5-- Page of <br /> Facility Address: � � Ci � Inspection Date: <br /> OUR- <br /> VA _ <br /> Chi- <br /> FA#: PR#: Program Element: <br /> S l U;71 065z <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum z 1,320 gallons in tanks*and containers**. <br /> Complete one box for each tank or each cumulative container product type. <br /> rank(2820) ❑ Containers (2821) #of Containers: TA#:Total Capacity: �-mU gallons Product Type: � ad <br /> (per tank or cumulative for containers by product type) Install Date: t)1'j`' N <br /> �'ank(2820) ❑ Containers(2821) #of Containers: TA#: A aaijle� <br /> 59 <br /> Total Capacity: 95bgallons <br /> Product Type: a i <br /> (per tank or cumulative for containers by product type) Install Date: Uoo j t) <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: Af-a,9 <br /> 3 Total Capacity: gallons Product Type: U pt <br /> (per tank or cumulative for containers by product type) Install Date: Ci <br /> Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> 4Product Type: Ql1 <br /> Total Capacity: J� gallons <br /> (per tank or cumulative for containers by product type) Install Date: 04"c 11• <br /> 1 "nk(2820) El Containers (2821) #of Containers: TA#: DSa'q! '6' <br /> 5 //Total Capacity: e gallons Product Type: (3i <br /> (per tank or cumulative for containers by product type) Install Date: Uti"rp-It.) <br /> Total Capacity this Page: gallons Total Capacity for Site: 9 gallons <br /> Comments: <br /> EHD Inspector: ReviewedDate: Entered ate: <br /> By Initial: 2 2�l 1 Z By Initial: <br /> *AbovegrouncTstorage tank means a tank that has the capacity to store 55 gal ons or more of petroleum. <br /> **Container means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 <br />