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Li) 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.orgiehd <br />ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />• _......, .._..,_. <br />Page / of I' Facility Add ss: City; <br />b . . - -3"A I-/ A iv -1- Pft FA #: <br />Inspection/Date:70 <br />7/ <br />3 4 C? <br />PR #: <br />A57 3/9 q-if j <br />Program Element: <br />L-4) W <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 />#of Containers: TA#: ank (2820) MI Containers (2821) Err <br />1 Product Total Capacity: -7.--e-, Type: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />#of Containers: TA#: ank (2820) • Containers <br />2 <br />(2821) <br />Product Type: /r------/c .5 F7 Total Capacity: 2,0-0 gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />0 Tank #of Containers: TA#: Containers <br />3 <br />(2820) (2821) <br />Product Type: Total Capacity: gallons <br />per tank or cumulative for containers by product type) Install Date: <br />#óf Containers: TA#: <br />4 <br />Tank (2820) • Containers (2821) <br />Product Type: Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />#Of Containers: TA#: i=1 <br />5 <br />Tank (2820) El Containers (2821) <br />Product Type: Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />Total Capacity this Page: gallons Total Capacity for Site:17L.O?)gallons <br />Comments: <br />Z:HD Inspector: <br />I <br /> <br />Reviewed Date: <br /> <br />. By Initial: 1 rn* in <br />Entered Date: <br />By Initial: /62 e349 <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 />EFID 28-01 <br />09/12/08 <br />AST SURVEY FORM