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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 />'OrXIFIVS <br />� <br />Page Z of <br />Facility Address: ylq <br />©��1A4�� <br />City: <br />Inspe ion Date: <br />ZdW <br />FA #: <br />/ %) <br />PR M <br />- <br />Progra Element: <br />z 573�0 <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground <br />storage of petroleum 21,320 gallons in <br />tanks* and containers**. <br />Complete one box for each tank or each cumulative container product <br />type. <br />Tank (2820) ❑ Containers (2821) <br />#of Containers:// TA#: b,6-1 <br />gg lQ <br />1 <br />Total Capacity: Z,j�D gallons <br />Product Type: / —A S <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 />Total Capacity: gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />3 <br />Total Capacity: gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />4 <br />Total Capacity: gallons <br />Product Type: <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 />Total Capacity: gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: gallons <br />Total Capacity for Site: <br />gallons <br />Comments: <br />EHD Inspector: <br />Reviewed <br />By Initial: <br />Date: <br />Entered <br />By Initial: <br />Date: <br />? <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 />09/17/08 <br />