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SAN JOAQUIN COUNTY _ _ -- ENVIRONMENTAL HEALTH DEPARTIV�,ENT 600 East Main Street, Stockton, CA 95202-30.'.9 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web. ww`v.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROF__.,AM SURVEY FORM) Facility Name: ,+ j Page Of / �%� l>P 1�J�A C� J � C' Inspe • Dat Facility Address: City: > 1:70 Pro L�d.,�r�c � 1 PR#: gram Element:: FA#: r� c7 G/ 7 Tank/Container Information Complete for all siteswhcumulative aboveground storage of pt ? gal tanks* and containers". o� let one box for each tank or each cumulative container t Tank (2820) El Containers (2821) #of Containers: TA#: ��i Product Type: 1 Total Capacity: () p 0 gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: Tank (2820) ❑ Containers (2821) 2 � �) � Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: 1,9, l l,z Tank (2820) ±Containers (2821) 3Product Type: Total Capacity: S Jr gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: Product Type: 5 Total Capacity: gallons (per tank or cumulative for containers by product type) nstall Date: �9,1'1o�n. TotailC7p�:�Wor Site: 0.> j gallons Total Capacity this Page: (j r Comments: Date, Entered Date: Reviewed Initial: 9� EHD Inspector: �� By Initial: � By�•ZJ� • / "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. —Container means a storage device designed to be moved when full. AST SURVEY FORM