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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 Name: <br /> Page--L of <br /> Facility Address: City: Inspection Date: <br /> 5r k v1 P-d vwo <br /> 1zED . ti <br /> FA#: PR#: Program Element: <br /> , <br /> 066 3�CL o '21 <br /> 2 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallon <br /> lative container product type._ <br /> ,2'-Tank (2820) ❑ Containers (2821) #of Containers: TA#: 19 'S�6D J 3 <br /> 1 Total Capacity: O gallons Product Type: 6 f";101 <br /> II` <br /> (per tank or cumulative for con ainers by product type) Wd in• N off �6 6 r <br /> Install Date: <br /> E l'Tank (2820) ❑ Containers (2821) #of Containers: TA#: app[ -4 <br /> 2TProduct Type: u�otal Capacity: 5&0allons �Yed <br /> (per tank or cumulative by product type) (0-6W 6M Urf61 d <br /> Install Date: <br /> ❑ Tank (2820) ,Containers (2821) #of Containers: � TA#: <br /> 3Product Type: �jP S A-E SD W-q Q <br /> Total Capacity: s� <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (2820) ZrContainers (2821) #of Contai <br /> <br /> <br /> R a <br /> Total Capacity: � gallons -� 1 <br /> (per tank or cumulative for coritairWrs product type) �t✓�h ►kola n l�p/yt�Q <br /> Install Date: <br /> ❑ Tank (2820) Containers (2821 TA#: D.h aDr91 `7 <br /> 5 Product Type: KqA� 61 <br /> Total Capacity: gallons yp - ""�`� ' .1 <br /> (per tank or cumulative for containers by product type) Install Date: DCOion-' w4iMena la 6L, f9rkr� <br /> Total Capacity this Page: gallons Total Capacity for Site: 6 [65gallons <br /> Comments: <br /> EHD Inspector: Reviewed l Date: Entered Date: <br /> IZ f� (0 By Initial: �v/_ -2 / By Initial: [ [� l� <br /> "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of pe oleum. <br /> "'Container means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />