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SAN JOAQUIN COUNTY <br />T 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: Dy <br />WOOD //e%?/ T d d P/ ,y/1 �� C/ <br />Page <br />Facility Address: City: <br />Inspectio Date• <br />F 1QG <br />FA #: <br />qm <br />TOI <br />PR #; <br />1� L� <br />Progra Element: <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks* and containers**. <br />Complete one box for each tank or each cumulative container product type. <br />M"'Tank (2820) ❑ Containers (2821) #of Containers: TA#: 0517_65 <br />1 <br />Product Type: �1--f� , S <br />Total Capacity: d P gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />ank (2820) El Containers (2821) #of Containers: TA#: � J 75 —9,2 <br />Product Type: e��'r <br />Total Capacity: �/-Od gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />#of Containers: 3 TA#: © �5 <br />[I Tank(2820) [P Containers (2821) <br />3 <br />Total Capacity: 115 gallons Product Type: 07 o 09 <br />(per tank or cumulative for containers by product type) Install Date: <br />#of Containers: TA#: s <br />19ZTank (2820) El Containers (2821) <br />4 <br />Product Type: Plu� <br />Total Capacity: 3 5a gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />El Tank(2820) [`Containers (2821) #of Containers:y TA#: Bh�� <br />5 <br />Product Type: %il/�.f TF 4� <br />Total Capacity: // y gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />Total Capacity this Pagallons <br />� L <br />Total Capacity for Site: gallons <br />�ommen�a <br />EHD Inspector: <br />Reviewed Date: <br />By Initial: A\j l ll, a <br />Entered Date: <br />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 />