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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: y <br /> eMr,N 1 Page �_ of <br /> Facility Address: City: InspectlotyDale <br /> 17 25 5. Ho ClTo D � z � <br /> FA#: PR#: Program Element: <br /> 17o o 0o?_ z <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) ❑ Contain s (2821) #of Containers: TA#: S/ <br /> 1 1 Product Type: <br /> Total Capacity: / G�-C gallons <br /> (per tank or cumulative for containers by product type) Install Date: 0 <br /> 2/Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 2 C Product Type: <br /> Total Capacity: J 0-0 gallons <br /> (per tank or cumulative for containers by product type) : r/,- n'-'y L'o'V <br /> 2'-Tank (2820) El Containers (2821) #of Containers: TA#: /9 b 1 �o <br /> 3 gallons Product Type: <br /> Total Capacity: 3 <br /> (per tank or cumulative for containers by product type) <br /> Install Date: / e I r 1,4/A �r-0^' <br /> El Tank (2820) L�1 Containers (2821) #of Containers: TA#: <br /> 4 Product Type: TPR, D I!U <br /> Total Capacity: / gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> N2/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5- <br /> 5Product Type: 11/A S <br /> Total Capacity: � 6­6gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallonsl Total Capacity for Site: � gallons <br /> Comments: <br /> 8 n) <br /> EHD Inspector:C �I Reviewed Date: Entered Date: <br /> Ifs By Initial: lv,1,� By Initial: <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 />