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SAN JOAQUIN COUNTY 09 <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 N e: <br /> Page o of <br /> Facility Address: !!jLA <br /> City: Inspection Date: <br /> S1} I <br /> FA M ti� l <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 /> {Tank (2820) ontainers (2821) #of Containers: TAM 25,W 7r� <br /> 1 Total Capacity: C gallons Product Type: _�� _ 61 ��U � <br /> (per tank or cumulative for containers by product type) ate: S► � <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: ��0'17�7'o2a2 <br /> 2 Total Capacity: SS gallons Product Type: LW0,r7,1nA i 61 <br /> (per tank or c lative for containers by product type) Install Date: �C'W- <br /> ❑ Tank (2820) t�lContainers (2821) #of Containers: TA#: �9 <br /> 3 r- Product Type: L Lj1- �. <br /> Total Capacity: _gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: TA#: <br /> 4 Total Capacity: oc� gallons Product Type: � A� i�) [ i('U'jXj j <br /> (per tank or cumulative for containers by product type) Install Date: zj"� <br /> El Tank (2820) L Containers (2821) #of Contain�� � TA#: <br /> 5 Total Capacity: 5tJ gallons Product Type 2� 6JA F. C <br /> (per tank or cumulative for containers by product type) `, <br /> Install Date: l/ 1'2 30� W t/�/ �j/I TN �� <br /> Total Capacity this Page: j ' gallons Total Capa I r ite: gallons <br /> Comments: <br /> EHD Inspector: -ReviewedDate: Entered Date: <br /> By Initial: V�. (� C 6 (3 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 <br /> 09/12/08 <br /> AST SURVEY FORM <br />