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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:_ n <br /> _ A RD ej 5 Page _ of <br /> Facility Address: City: Inspection ate: <br /> 2 64 �C S D W �� .`� <br /> FA#: PR M Program Element: <br /> 53- 21 <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 /> O Tank (2820) ❑ Containers (2821) #of Containers: TA D5/�qSZ <br /> 1 �� d Product Type: <br /> Total Capacity: �� � gallons - <br /> (per tank or cumulative for containers by product type) Install Date: <br /> #of Containers: TA#: P,6-1 723 <br /> M/Tank (2820) El Containers (2821) Q <br /> 2 Product Type: ���, ' U <br /> 7 <br /> Total Capacity: Z P 47(9 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) n Containers (2821) #of Containers: S' TA#: ©J-1 <br /> 3 /-' Product Type: �iI/r� T` 6-1 (i <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) 1:1Containers (2821) #of Containers: TA#: 55-10 <br /> `J / <br /> 4 - 7 q Product Type: � � <br /> � <br /> Total Capacity: ,> � G gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> #of Containers: TA#: <br /> C9'Tank (2820) B/Containers (2821) <br /> 5 Product Type: /--f/'v <br /> oll;z <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons TTotal Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed � �A Date: Entered Date: <br /> U <br /> By Initial: '�-i'�-� By Initial: �e <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more ofYetroleum. <br /> **Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />