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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 />1�Al%, <br />fvC/' <br />Page of <br />Facility Address: City: <br />6 c� tt �' 7-6 rl AL <br />Inspecti n Dat <br />r �= <br />FA #: <br />PR #: <br />s, C <br />Program Element: <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground <br />storage of petroleum >_1,320 gallons in tanks* and containers". <br />Complete one box for each tank or each cumulative container <br />product type. <br />0 Tank (2820) ❑ Containers (2821) <br />#of Containers: rTA#: A6 1 SIP 7 D <br />1, <br />Total Capacity: / 0 � ©� allons <br />Product Type: /'�.! �_D <br />x <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />2 <br />/ <br />Total Capacity: %,�.� - � � gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />i <br />C�Tank (2820) El Containers (2821) <br />#of Containers: TA#: (g/� % a <br />3 <br />Total Capacity: loo?) gallons <br />Product Type: U���� <br />J. <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) f,nnfniners (2821) <br />Install Date: <br />#of Containers: TA#: c <br />4 <br />Total Capacity: gallons <br />Product T�- <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />5 <br />Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: - ' gallons <br />L, U <br />Total Capacity for Site:gallons <br />Comments: <br />EHD Inspector. / "' <br />Reviewed Date: <br />} <br />By Initial: vtj '�. b-0 <br />Entered DateWw <br />By Initial: 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 />