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SAN JOAQUIN COUNTY 4_ i <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.orglehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> ✓0A41 <br /> Page -:?—of <br /> Facility Atldrsss: City- Impaction ta: <br /> 711 <br /> fA#: / PR#: Pr 7 EI : <br /> ZlL r <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum x1,320 gallons in tanks"and containers". <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) u Containers (2821) #of Containers: TAS <br /> #: <br /> 1 Total Ca act C � s, ProductType: <br /> p ty:�gallons <br /> (per lank or cumulative for contalnars by product type) Install Date: <br /> I§ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4�Dlc <br /> 2 Total Capacity: i b o gallons Product Type: >� <br /> (per tank or CurnUlative for Containerb by product type) Install Date: <br /> Tank (2820) Ci Containers (2821) #of Containers: _TA#: b7 1 c( tpq <br /> 3 Total Capacity: gallons Product Type: Li �} )// _ <br /> (per tank or Cumulative for containers by product type) Install Date: I I"�"""7— l.°td A X-0,11 <br /> Cl Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 0 Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or oumuletive for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Irrspecinr: TReviewed Date: Entered 1 Date: <br /> By Initial: By inibai ? i <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 /> £HO 2941 AST SURVEY FORM <br /> M12ioa <br />