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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 /> Page _( of l( <br /> Facility Address: City: Inspection Date: <br /> kCTu0- �n Lc t2-S—CI/ <br /> FA#: PR#: _ Program Element: <br /> 0000?`l0�-� 0 '2q 17-2 Z <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks* and containers". <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) El Containers (2821) *of Containers: TA#: ©�U 77�a <br /> 1 Product Type: <br /> Total Capacity: (0 , 0-0O gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: Y TA#: A6-1 7 7,13 <br /> 2 t C Product Type: T'RAN`2l`11 5, o� r <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: Q�') `Z 7 3!� <br /> 3Total Capacity: _�,0y gallons Product Type: A'40RA—L-' (- 40I L_ <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: r56_l -77L� <br /> 4 Product Type: Oil— <br /> (per <br /> t l— <br /> Total Capacity: e;0-0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: t D? I D gallons 1 Total Capacity for Site: {- 1 0 t LD gallons <br /> Comments: QL� b1J S T� i2- S -p� A5TPLC"_L—q o <br /> 1—�O� K`t ln�►J , <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: V i_�_o°1 By Initial: <br /> 'Aboveground storage tank means a tank that has the capacity to store 55 gallons or more o etroleum. <br /> —Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />