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f y 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 />113 r' �� A/0 <br />Page of <br />Facility Address: S City: <br />2a2 0 A , <br />Inspec ion a <br />i o <br />FA M <br />17 g <br />PR M <br />5a <br />P C( �o <br />Prog�m�Elemer}�: <br />Tank/Container Information <br />Co Tete 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) ElContainers (2821) #of Containers: , TA#: f g. <br />1 <br />l <br />Total Capacity: �nn gallons Product Typt <br />(per tank or cumulative for containers by product type) Install Date: <br />VTank(2820) ❑ Containers (2821) #of Containers: TA#: <br />2 <br />Product Type: <br />Total Capacity: b gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />#of Containers: <br />Tank (2820) Containers (2821) _ TA#: G251$� 1 <br />3 <br />Product Type: %l'1 Gt <br />Total Capacity: 'Z, gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />Tank (2820) J Containers (282 1) #of Containers: TA#Q <br />4 <br />/ <br />Product Type: 1-// �/ P <br />2- 15 <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />El Tank (2820) Containers (2821) #of Containers: TA#: D `� latSc3�v 3 <br />5 <br />Product Type: lizza <br />Total Capacity: 7L(9,0 gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />Total Capacity this Page: gallons <br />Total Capacity for Site: 1 D gallons <br />Comments: <br />EHD Inspector: i /� <br />L_ <br />Reviewed Date: <br />By Initial: Cj'" l5 <br />Entered Date: <br />By Initial: <br />TIC D <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 />