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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 /> z_.eqqe& Page of `5 <br /> Facility Address: City: Inspectifln <br /> c,2,05 Al 1"Q e,¢-�� Date: <br /> /vim 9/��/io <br /> FA#. PR#: <br /> Program Element: <br /> x,.32 <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: TA#: '9"51 o2 <br /> 1 e: <br /> Total Capacity: a�� gallons Product Type: C <br /> (per tank or cumulative for containers by product type) Install Date: D�/ <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: ,5)6j q 4 <br /> 2 Total Capacity: ��cj Product Type: Hgdll?�� &j/ <br /> P Y� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: D <br /> 3 <br /> Total Capacity: �c <br /> Product Type: O7 <br /> �� gallons <br /> (per tank or cumulative for containers by product type) Install Date: �-o O <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: �9�i )' <br /> 4 Product Type: (tel G(�f�7�Q77Zp �j <br /> Total Capacity: 45 $ gallons <br /> (per tank or cumulative for containers by product type) Install Date: CLI <br /> °Tank (2820) ❑ Containers (2821) #of Containers: TA#: $ <br /> 5 Product Type: /ate_l��r��j7-cp 67 <br /> Total Capacity: �� gallons <br /> (per tank or cumulative for containers by product type) Install Date: o q <br /> Total Capacity this Page: gallons Total Capacity for Site: 74-4'9 gallons <br /> Comments: <br /> EHD Ins ctor: Reviewed Date: Entered Date: —F' <br /> By Initial: By InitialT <br /> ID <br /> *A vegr nd storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> **Co'nWner means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />