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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 />/,Xq r C <br />Page L of <br />Facility Address: City: <br />Inspection/Date: <br />FA #: 9 /� <br />1 50� <br />PR #: <br />Progra Element: <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 />2 Tank (2820) ElContainers (2821) #of Containers: TA#: <br />1 <br />� ©v Product Type: L)/7-"� <br />Total Capacity: � gallons / <br />(per tank or cumulative for containers by product type) Install Date: <br />Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />2Product <br />Total Capacity: .�1� gallons Type: <br />(per tank or cumulative for containers by product type) Install Date: <br />ank (2820) ❑ Containers (28P #of Containers: T�#: i9,-) ItAOT <br />3 <br />Product Type: Z/iL2� <br />Total Capacity: 1P gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />#of Containers: : D� I o2D <br />Tank (2820) ElContainers (2821) <br />4 <br />Product Type: � <br />Total Capacity: / e -VO gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />.P -"rank (2820) ❑ Containers (2821) #of Containers: TA#: 10 <br />5 <br />r'" Product Type: 47x 2—& <br />Total Capacity: J gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />Total Capacity this Page: gallons <br />Total Capacity for Site: �j D gallons <br />Comments: ` - O. 1 D `aT <br />(-207 ::�' 0 <br />O!'?b P <br />V <br />EHD Inspector: <br />Reviewed Date: <br />By Initial: �. t <br />Entered Dater <br />By Initial: / _ g <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 />