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,i <br /> _ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> =y 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: T LIMm� A Page / of <br /> J Z o f= Gv�S. <br /> Facility Address: City: Inspec ion De; <br /> W�, /a/7,910'g <br /> FA#: PR#: Progral <br /> DD l 3 a PI-6-Z it ' <br /> Tank/Container information <br /> Complete for all sites with cumulative aboveground storage of petroleum 11,320 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: TA#: <br /> 1 Product Type::0-4Onn Q ) <br /> Total Capacity: ��� gallons <br /> (per tank or cumulative for containers by product type) Install Date: ' <br /> El Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 2 Total Capacity: gallons Product Type: _ <br /> (per tank or cumulative for containers byproduct type) Install Date: 3 <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (2820) ElContainers (2821) #of Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (2820) ElContainers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> I (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for site: Z J b gallons <br /> Comments: <br /> o ,� s <br /> 7)J0 A" <br /> EHD Inspector: ✓ Reviewed Date: / Entered Date: <br /> By Initial: U By Initial: <br /> I *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 /> EHD 28.01 AST SURVEY FORM <br /> 09/12108 <br />