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SAN JOAQUIN COUNTY 40 <br /> INVIRONMENTAL 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: I ^ <br /> 1� 14 Page —L— of <br /> Facility Address: City: Inspe tion Dat <br /> 2 2 2 2 S , i r-} G r S{v c IGS., (& 0 e7 <br /> FA#: 68 PR P. n Prog am Element: <br /> Tank/Container Information 2 <br /> Complete for all sites with cumulative aboveground storage of petroleum ?1,320 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#: Y2 <br /> 1 Total Capacity: bU gallons Product Type: t <br /> c nlest Z <br /> (per tank or cumulative for ainers by product type) <br /> Install Date: <br /> Tank (2820) ontainers (2821) #o ontainers: T <br /> 2 Total C acity: gallons Produc e. <br /> i <br /> (per tank orc ulatie. <br /> for containers by produc type) <br /> Install Date: <br /> ❑ Tank (2820) XContainers (2821) #of Containers: TA#: / <br /> 3 Total Capacity: S.� gallons Product Type: 144A <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ❑ Tank (2820) "Containers (2821) #of Containers:,t f' TA#}:: <br /> Total Capacity: <br /> 4 gallons Product Type: M0�i ( UIFr X �f4 � <br /> (per tank or cumulative for con aine s by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: TA#: <br /> 5 Product Type: &4 • blor-) olil, D�lv <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: Z s gallons <br /> Comments: <br /> V <br /> EHD lnspgWQr: Reviewed Date: Entered Date: <br /> Vn By Initial: VIIJ By Initial: �. <br /> *Aboveground Istorage 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 /> 09/12/08 <br />