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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 />--i <br />jr--�G d 0- /-1, —F b) - J <br />Page Z of <br />Facility Address: �/J <br />-2-17-1 <br />City: <br />Inspection Date: <br />r^L�try---•— /�t�\ <br />a %'L <br />23 c> 9 <br />FA #: PR #: <br />OZ) -709 6 <br />Program EI ment: <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 />2- Tank (2820) ElContainers (2821) <br />#of Containers: <br />1 <br />Total Capacity: Zoo o gallons <br />pTA#: <br />Product Type: <br />/(per tank or cum lativeefforr containers by producttype) <br />Install Date: <br />''Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />2 <br />Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative for 6ntainers by product type) <br />Ja Tank (2820) ❑ Containers (2821) <br />Install Date: <br />#of Containers: TA#: <br />3 <br />_ ! i c-,%,-= <br />Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative for containers by pro—duct type) <br />Tank (2820) ❑ (2821) <br />Install Date: <br />#of Containers: TA#:Containers � T---- <br />4 <br />Total Capacity:_ gallons <br />Product Type: <br />(per tank or cumulative for containers by type) <br />his L- 5 <br />Install Date: <br />I <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />5 <br />Total y:_ gallons Capacity:_ <br />p <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: <br />gallons <br />Total Capacity for Site. gallons <br />Comments: <br />JqiW <br />EHD Inspe <br />Reviewed Date: <br />Entered Date'/' <br />By Initial: <br />By Initial:YT �a B <br />*"z/�Veground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br />�PContainer means a storage device designed to be moved when full. <br />Is <br />EHD 28-01 AST SURVEY FORM <br />09/12/08 <br />