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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 />E 2 E 11,01G AA2 <br />Page of <br />FacilityAddress: City: <br />a <br />Inspection ate: <br />/� <br />-v <br />FA #: <br />PR #: <br />Program El ent: <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 />1 <br />Conk (2820) 1:1 Containers (2821) #of Containers: TA#: �j `�5 7 Z <br />Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />R Tank (2820) ElContainers (2821) #of Containers: TA#: /96 <br />2 <br />Product Type: ,2 / <br />Total Capacity: Fe% gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />L�YTank (2820) ElContainers (2821) #of Containers: TA#:ji'I <br />3 <br />Product Type: A_ � <br />Total Capacity: f � gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />LAY (wank (2820) ❑ Containers (2821) #of Containers: TA#: �5_/ <br />4 <br />Total Capacity: ,/"Irfi gallons Product Type: <br />(per tank or cumulative for containers by product type) Install Date: <br />ank (2820) ❑ Containers (2821) #of Containers: TA#: <br />5Product <br />Total Capacity: ,�� gallons Type: <br />(per tank or cumulative for containers by product type) Install Date: <br />Total Capacity this Page: -� s-rj-Ci gallons <br />Total Capacity for Site: gallons <br />Comments: )" <br />EHD Inspector: <br />Reviewed Date: <br />By Initial: -1.'�. V� <br />Entered Date: <br />By Initial: <br />*Aboveground orage 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 />