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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: <br /> /V F— l lU T y L d `' (� OM $ r- Page —L of <br /> Facility Address: City: Inspecti n Dat O <br /> Z9 2,$o , , (��� y <br /> FA#: PR M Program Element: <br /> 0 153 Z g6 <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 /> Tank (2820) ❑ Containers (2821) #of Containers: TA#-. 0,6-/ S`5�7 <br /> 1 Total Capacity: r gallons Product Type: Z2 _J <br /> (per tank or cumulative for t6ntainers by product type) Install Date: <br /> anl (2820) ElContainers (2821) #of Containers: TA#: h( 06S"�' $ <br /> 2 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for con ainers 15y product type) Install Date: <br /> ❑ Tank (2820) P Containers (2821) #of Containers: 7— TA#: '�?B' <br /> 3 � Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: TA#: D51 �fl <br /> 40 Product Type: �/D f Ori— O/ <br /> Total Capacity: Z� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (2820) M ontainers (2821) #of Co finYpers: TA#: <br /> �1(i J <br /> 5 Total Capacity: '?—d gallons Prod t T e: Cjl <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: O gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> C _ By Initial: � �•��- By Initial <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more 6f pe roleum. <br /> **Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09112/08 <br />