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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: / CJ <br />Page ( of <br />Facility Address: <br />City: �Insp: 1n t tkl//V� , 1 I <br />[J <br />FA M T^ PR M Progr m EI nt: <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 />Tank (2820) ❑ Containers (2821) #of Containers: T�^A,11#:���9j� <br />1 (((Product Type: <br />Total Capacity:' gallons <br />(per tank or cumulative forntainers by product type) Install Date: <br />Tank (2820) ❑ Containers (2821) #of Containers: ( <br />2 Total Capacity: � (,Q _gallons C Product Type: ow d I <br />(per tank or cumulative for co tainers by product type) Install Date: <br />Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />Total Capacity: gallons <br />3 Product Type: �� <br />(per tank or cumulative for containers by product type)) <br />Install Date: <br />❑ Tank (2820) WContainers (28210"A <br />#of Containers: g' <br />4 Total Capacity: Aensuct Type: (� 0 i L - <br />(per tank or cumulative roduct type) <br />Install Date: <br />El Tank(2820) Containers (282 #of Containers: I <br />5 roduct Type: <br />fvuiti� <br />Total jorcurn <br />city: ns <br />(per tanul finers by product type) <br />Install Date: <br />Total Capacity this Page: b� gallons TTotal Capacity for Site: gallons <br />Comments: + �s <br />oi��I <br />VS :JPA► wf--� <br />i <br />EHD Inspector: Reviewed Date: tEyntered Date�Ah e-(q.il By <br />In Q��� H ' `� 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 <br />09/12/08 AST SURVEY FORM <br />