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SAN JbAQUIN COUNTY f *NVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: �4 u Page I of l Q 1v City: Inspection Date: Facility Address:ts r ( 2 5 019 4'3 '3 L, '� > PR M Program a ement: FA#: 947 � " S 2� Tan Container Information Complete for all sites with cumulative aboveground tank o�reach cumulative ontainegrallons in roduct type. a * and containers'*. Com fete one box for each #of Containers: . TA#: p'/Tank (2820) ❑ Containers (2821) 1 Product Type: Total Capacity: ''"o UP gallons (per tank or cumulative for containers by product type) Install Date: ^` #af Containers: TA#: L•9' Tank (2820). ❑ Containers (2821) � � s 2 Product Type: Total Capacity: L�0 gallons tin (per tank or cumulative for containers product type) Install Date. ED] Tank (2820) 101Containers (2821) #of Containers: TA* 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: � TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers. TA#: Product Type: 5FTotal Capacity: gallons (per tank or cumulative for containers by product type) Install Date: 4 Total Capacity this Page: V gallons Total Capacity for Site: �V gallons Comments: Reviewed Date: �Entered Date: EHD Inspector. ` r By Initial: al: I *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 FORA EHO 28-01 noxa-wna _