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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />• 600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (2 9) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />Facility Na e: <br />3 /—J_( <br />Page of <br />Facility Address: City: <br />o ,� G <br />Inspectio Dat <br />. Q� <br />FA #:PR <br />M <br />Program Ele nt: <br />el6c 50 <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 />Tank (2820) El Containers (2821) #of Containers: TA#: )96-)��� <br />• <br />1Product <br />Total Capacity: 104"0 gallons Type: 0 <br />(per tank or cumulative for containers by product type) Install Date: <br />Tank (2820) ❑ Containers (2821) #of Containers: TAn#: k-) <br />2 <br />Product Type: <br />Total Capacity: 3 o -&z'9 gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />2 Tank (2820) OIContainers (2821) #of Containers: TA#: BSI <br />3Product <br />Total Capacity: f % T gallons Type: %127277 � a/` <br />(per tank or cumulative for containers by product type) Install Date: <br />#of Containers: TA#: <br />El Tank [2 Containers <br />Tank <br />(2820) (2821) <br />4 <br />r Product Type: �`1.��/�0`` <br />l ; <br />Total Capacity: J gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />El Tank (2820) [containers (2821) #of Containers: TA#: <br />5 <br />Product Type: C C' <br />-2i <br />Total Capacity: _"' gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />Total Capacity this Page: C 3 �(� gallons <br />Total Capacity for Site: 13S—IM gallons <br />Comments: <br />D <br />1�16 46 0 Q06 <br />EHD Inspector: <br />�'� <br />Reviewed Date: <br />By Initial: ,�.,-�� <br />Entered Date: <br />By Initial:�2 /'9/10 <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 />