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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 />o.1d4)-VW ac-�in In(- <br />Page i—of 2 <br />- <br />Facility <br />Facility Address: City: <br />ADD �. ���-�ri! <br />Inspection Date: <br />� 2 / / zoos <br />���-�a� <br />� <br />FA #: <br />0p0 �- i <br />PR #: <br />31 la <br />Program Element: <br />.� *32 <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 />(A Tank (2820) ❑ Containers (2821) #of Containers: i TA#: <br />1 <br />Product Type: � �- CfuYY2�i� ncf n <br />Total Capacity: �� ' gallons yp ��— <br />(per tank or cumulative for con ainers by product type) Install Date: f //1 <br />❑ Tank (2820) IAC ntainers (2821) #of Containers: 2- TA#: 12 <br />D <br />2 <br />Tota a acit gallons Product Type: L � � <br />1.p y <br />per tank or cumulative for containers by product type) Install Date: Uel k -n o w✓1 <br />El Tank 2820 #of Containers: TA#: 9.5-i qh� <br />( ) J�Containers (2821) <br />3 <br />Product Type: ��jj <br />�M iVI.,P/YuX._ <br />Total Capacity: gallons j' <br />(per tank or cumulative for containers by product type) Install Date: 011 kn 0l'o /l <br />#of Containers: TA#: 5 <br />❑ Tank (2820) j8("ontainers (2821) <br />4 <br />n <br />_` t o0 Product Type: Dr e ��'fr« <br />Yogi Capacity:_ gallons <br />� ,,/� <br />per tank or cumulative for containers by product type) Install Date: %�? � k ""' <br />Subs + lave s <br />Tank (2820) Containers (2821) #of Containers: TA#: <br />5 <br />Total Capacity: / 5-0() gallons Product Type: <br />, ) <br />(per tank or cumulative for containers by product type) Install Date: l/11 �->sr <br />.ta car 6'u1Y <br />Total Capacity this Page: gallonsTotal <br />Capacity for Site: L41 -70 j gallons <br />Comments: <br />ev <br />U <br />EHD Inspector: <br />Reviewed Date:E rad' Date: <br />By Initial: 1�,� l�. Initial: 1 <br />HDovegrouna storage fall 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 />09/19/08 <br />