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r <br />a 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 />�DxMAkTrN /f' Lf1mgs <br />21/ <br />Page ofT_ <br />Facility Address: l City: <br />AJ <br />Inspection Date: <br />- <br />FA #: <br />/ ZZ—Z,- <br />PR #: <br />Program Tent: <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 />1B Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />1 <br />Product Type: Alia4 S <br />Total Capacity: �C� C3 gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />0 Tank (2820) ElContainers (2821) #of Containers: TA#: /19,5 <br />2 <br />Total Capacity: '12 p gallons Product Type: <br />(per tank or cumulative f6r containers by product type) Install Date: <br />EV /Tank(2820) ElContainers (2821) #of Containers: TA#: <br />3�� <br />Product Type: /� 10 7- al -Z, <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />❑ Tank (2820) ® Containers (2821) #of Containers: TA#: <br />4Product <br />Total Capacity: ✓C.S gallons Type: <br />(per tank or cumulative for containers by product type) Install Date: <br />D`Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />5 <br />Product Type: <br />Total Capacity: Z.�G� gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />Total Capacity this Page:3.s—5, gallons <br />Total Capacity for Site: 3 �"�'J gallons <br />Comments: <br />EHD Inspector: <br />C ` <br />Reviewed Date: <br />By Initial: (�_(p.nPt <br />Entered Date: <br />By Initial: Iq 0 <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 />