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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 />— L1 «,i L„a, „aJ uic c,CIPOURy w store oo gallons or more of petroleum./ <br />**Contain s a storage device designed to be moved when full. <br />EHD 28-01 <br />09/12/08 AST SURVEY FORM <br />Facility Name: \ <br />Pageof <br />_T_ <br />Facility Address: <br />C�City: <br />�4il�l l Lam <br />� <br />Inspection Date- <br />ate: <br />FA <br />FA#: MODD�3� PR#: <br />�� (� (� <br />O <br />Progr Elem nt: <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 />Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#`:��/ Cj 72 <br />1 <br />otal Capacity: acit C 3� gallons <br />Product Type: C(i1 (5) I <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />XL -PC 30 <br />Tank (2820) El Containers (2821) <br />#of Containers: TA#: r L� <br />4 <br />2 <br />Total Capacity: Oi gallons <br />Product Type: W( (,( ,Y Vol reS1� d) <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />[Tank (2820) El Containers <br />Containers (2821) <br />Containers: TA#: <br />3 <br />Total Capacity: acit X10Lfb gallons <br />Product Type: 1'io ( G 4wk-1� <br />(per tank or cumulative for containers by product type) <br />Install Date: / Q <br />V-A Tank (2820) F1 Containers (2821) <br />#of Containers: TA#: 6,5—) Q 7a. <br />4 <br />l (� ' <br />Total Capacity: <br />Product Type: <br />gallons <br />(per tank or cumulative for containers by product type)/ <br />Install Date: (, <br />V Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: 7 <br />5 3Product <br />Total Capacity: <br />Type: <br />gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: gallons T Total Capacity for Site:o d— gallons <br />Comments: <br />EHD Inspector: <br />Reviewed <br />By Initial: <br />Date: <br />Entered Date: <br />By Initial: <br />*Aboveoro ncf stnrn tanlr mann. + V <br />*i, + ti.,._ �i_— . <br />— L1 «,i L„a, „aJ uic c,CIPOURy w store oo gallons or more of petroleum./ <br />**Contain s a storage device designed to be moved when full. <br />EHD 28-01 <br />09/12/08 AST SURVEY FORM <br />