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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 Nam—e:: /Q <br /> r� QT�.r Page� of <br /> Facility Address: syr City: Inspection Date: <br /> FA <br /> PR#: Program 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 /> ff(Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Product Type: �j/ � <br /> Total Capacity: l�j�( gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: 7 <br /> 2Product Type: agg' 7rj21j2 D/�/L�O�ZQ �/21f <br /> Total Capacity: /50 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Wcontainers (2821) #of Containers: 40 <br /> T #: b,h) Q' -7�4 _ <br /> 3 � Q Product Type. �J <br /> Total Capacity: aQgallons <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ❑ Tank (2820) eContainers (2821) #of Containers: _1 TA#: 4? <br /> 4 Product Type:Alec?e <br /> Total Capacity: `J�gallons <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: 401 TA#: <br /> 5Product Type: &ecZr�!'7C <br /> Total Capacity: 010W 43�49gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: /(��� gallons Total Capacity for Site: � 2 gallons <br /> Comments: <br /> EHD Ins r: f _ Reviewed Date: Entered Date: <br /> By Initial: By Initial: <br /> "Abcr6egrq,dhd storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> "Co er means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />