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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 Nam <br /> `lCLI2� fjl�GGtiI�JJ ^7L(ClL��1op . Page / of Z <br /> Facility Address: City: Inspe tion Dat : <br /> 5,o S. flus qq Q� c��t�r� ��2s�i/ y <br /> FA#: PR M Program Element: <br /> 100Lo5B D 52813 a83/ <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 Q <br /> 1 Product Type: D f D k- <br /> DO <br /> Total Capacity: gallons <br /> pertank or cumulative for containers by producttype) Install Date: <br /> Tank (2820) 13 Containers (2821) <br /> #of Containers: TA#: 19,6-12911p <br /> 2Product Type: /jam(D 1-4) t 07-1 <br /> Total Capacity: 2 D (� gallons <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> IXTank (2820) ❑ Containers (2821) #of Containers: ,r '/)fpY <br /> TA#: 196.9/9/lo D <br /> 3 / <br /> Total Capacity: 20 gallons A <br /> Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> xTank (2820) ❑ Containers (2821) #of Containers: TA#: ,P,5-RP l /o <br /> 4 Total Capacity: 4 00 gallons Product Type: l 'sf d o/ l <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ❑ Tank (2820) Xcontainers (2821) #of Containers: <br /> 5 Total Capacity: gallons Product Type: /i/l0 fD Q/ <br /> (per tank or cumulativefor`containers by product type) Install Date: <br /> Total Capacity this Page: "(/ 3a uall-nsl Total Capacity for Site: gallons <br /> Comments: <br /> 5 S 5 an <br /> -7T l W au n e�7 O N <br /> F—0- <br /> EHD I ect _ Reviewed Date: Entered Date: <br /> By Initial: of U,\ ` By Initial: <br /> *AVv,pjOround storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> "C ntainer means a storage device designed to be moved when full. <br /> EHD 28-Cl <br /> 09/12/08 AST SURVEY FORM <br />