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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 /> "T Cla/7 Page of 2 <br /> Facility Address: r City: Inspection Dte: <br /> O 117 S. IL44 C a /91 /O <br /> FA#: 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 /> —/ <br /> Complete one box for each tank or each cumulative container product type. <br /> Lid" Tank (2820) ❑ Containers (2821) #of Containers: TA#: 9, r q' <br /> _Total Capacity: 2 2 D gallons Product Type: aSC d 0/' ( <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> El Tank (2820) E(Containers (2821) #of Containers: TA#: <br /> 2Product TypTotal Capacity: O gallons e. <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> El Tank (2820) 14 Containers (282 1) #of Containers: l o TA#: /S_J L?7 7j <br /> 3 Total Capacity: 9� 0 Product Type: Hud-gc�Qic / Qy��l2 <br /> � p y: gallons <br /> (per tank or cumulative for containers by product type) d r O/ <br /> Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: �_ TA#: g 73 <br /> Total Capacity: 'D 45gallons Product Type: �rn(10_rL-A -� <br /> (� (per tank or cumulative for containers by product type) <br /> Install Date: <br /> 12 Tank (2820) ElContainers (2821) #of Containers: <br /> <br /> roduct Type: dpq/ �( rp,' One <br /> Total apacity: � `J� gallons <br /> or cumulative for containers by product type) Install Date: <br /> Total Capacity this P r✓ 15 gallons Total Capacity for Site: 110&S gallons <br /> Comments: <br /> i r <br /> EHD Inspe or: Reviewed Date: Entered DateL I : <br /> F By Initial: 17,L`l,�Q By Initial: <br /> *Abov(gr5drrd storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> "Con ' er means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />