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ry ' <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 Name: b r L� <br /> Lou , S 10 V/9 N_ go N 1 1 3 Page_�of <br /> Facility Address:' City: Inspecti -Da e• <br /> FA#: PIR#: Pro lament: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum X1,320 gallons in tanks* and containers`*. <br /> Cam tete one box for each tank or each cumulative container product tyRe. <br /> L44ank (2820);.,. ❑ Containers (2821) #of Containers: TA#: <br /> 1 F © � Product Type: <br /> Total Capacit ,- / gallons <br /> (per tank or,cum a for containers by product type). Install Date: <br /> U ank"(2820) ElContainers (2821) #of Containers: TA#: <br /> 2 Total Capacity: �f?tj gallons Product Type: I� <br /> (per tank or cumulative for containers by product type) l nstall Date: <br /> Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> f' 3 =� Product Type: ��S YZ <br /> Total Capacity: 67C) gallons <br /> (per tank or cumulative for containers by product type) Install Data: <br /> ❑ Tank (2820) E3Containers (2821) #of Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> f ElTanki(2820) ❑ Containers (2821) <br /> #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) 1 nStall Date: <br /> Total Capacity this Page: % 3 al-0 gallons Total Capacity for Site: gallons <br /> Comments: 7 <br /> O � i✓ '' � L71fvr C7'i40V k (V/`— . <br />{ EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: (L,02! <br /> "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> r "Container means a storage device designed to be moved when full. <br /> EHD 28.01 1 AST SURVEY FORM <br /> aeil2ros <br />