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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 />S <br />Page of <br />0jj9d211V1ArV <br />—Z— <br />Facility Address: City: <br />21 S- <br />Inspection Date: <br />2,f07 <br />FA #: <br />PR #: <br />Program Element: <br />2t <br />O moa <br />-2-'R a <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) ❑ Containers (2821) #of Containers: TA#: (05- <br />1Total <br />E1915-113 <br />Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />W/T/'ank (2820) ❑ Containers (2821) #of Containers: TA#: $ 4, 5 �� <br />2 <br />Total Capacity: J 4 gallons Product Type: <br />(per tank or cumulative for containers by product type) Install Date: <br />Tank (2820) El Containers (2821) #of Containers: TA#: aQ: t 9,626-3 <br />3 <br />Product Type: ��1/!Q S�� gf <br />Total Capacity: Z.� gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />#of Containers: TA#: Qh / <br />Containers <br />El Tank (2820) (2821) <br />4 <br />Product Type: o;Z5 <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />#of Containers: <br />El Tank (2820) It�'Containers (2821) ✓ TA#: <br />5 <br />Product Type: , / V/Z vi <br />Total Capacity: //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: IZ12,L gallons <br />Comments: <br />EHD Inspector:, <br />Reviewed Date: <br />By Initial: 1 �b <br />Entered Date: <br />By Initial: <br />o2i <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 />