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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 /> P/C�IGr� Page of 2 <br /> Facility Address: City: Inspection Date: <br /> FA#: PR#: 6 �8 <br /> Program Element: <br /> d0// 22� 6 a/ <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 /> Q Tank (2820) ❑ Containers (2821) #of Containers: TA#: _r9� lq�J / <br /> 1i��� Product Type: <br /> Total Capacity: � gallons <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ❑ Tank (2820) C/Containers (2821) #of Containers: l� TA#: <br /> 2Product Type: <br /> Total Capacity: 0 gallons <br /> (per tank or cumulative for containers by product type) I O <br /> Install Date: <br /> ElTank (2820) LV'Containers (2821) #of Containers: TA#: q-7 � <br /> 3 Total Capacity: GJ gallons Product Type: 1y�1C1�/'aCQ1�07'1�C�rf�j/� ¢ <br /> (per tank or cumulative for containers by product type) Install Date: <br /> LTJ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 42'�Ej1:2 q- <br /> 4 Product Type: &SPgr D/ <br /> Total Capacity: 2 2 C-) gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: 77�j <br /> 5 Total Capacity: /50 gallons Product Type: 63222e <br /> (per tank or cumulative for containers by product type) f�PCL r�1 <br /> Install Date: <br /> Total Capacity this Page: gallons TTotal Capacity for Site: � � gallons <br /> Comments: <br /> EHD Ins ctor: _ Reviewed Date: Entered ;-° Date: <br /> By Initial: �T✓�,"�! tj-2_q. l'U By it, <br /> : s� <br /> "Abov storage tank means`za tank that has the capacity to store 55 gallons or more of petroleum. GL <br /> "ContAine,f means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />