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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 />Page2, of <br />Facility A00ress: <br />J <br />City:C/�, v <br />� j% <br />Inspectio Date:- - <br />/o yi <br />FA #: PR #: <br />40,5.-2 =-,2-1 -70 <br />Program Element: <br />ZF�b <br />Tank/Container <br />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 />11 Tank (2820) °i'Containers (2821) <br />#of Containers: _f�TA#: D �,Q�} 1 <br />1 <br />.33 b <br />Total Capacity: gallons <br />Product Type: �,�S Gig O-, <br />, <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) Containers (2821) <br />#of Containers: _LTA#: .3 <br />2 <br />Total Capacity: `J �J gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) Xcontainers (2821) <br />#of Containers: TA#: <br />3� <br />Total Capacity: a� ga Ions <br />Product Type: %/ hZ4� <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ <br />#of Containers: a TA#: r <br />Tank (2820)�ccntainers (2821) <br />Total Capacity: a gallons <br />:ao4 roduct Type: <br />(per tank or cumu ontainers 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: - 4 gallons <br />Total Capacity for Site: --71 �g gallons <br />Comments: <br />EHD Insp tor: <br />Reviewed �- Date: <br />By Initial: <br />Entered Date: <br />By Initial: /� <br />f <br />"Abov gro storage tank me that has the capacity to store 55 gallons or more of petroleum. <br />**ConULp6r means a storage device designed to be moved when full. <br />EHD 28-01 AST SURVEY FORM <br />09/12/08 <br />