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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 PRO-GRAM SURVEY FORM <br /> Facility Name: r O _1 V S' R 4 LR M / d't / 1I 5 Page <br /> J I Of <br /> Facility Ad s tvy / City: Inspect on D teQ <br /> 1 <br /> FA#: � � � PR Program fe'/nit: <br /> K3,!�59 U <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 /> �/(ank (2820) ❑ Containers (2821) #of Containers: _ ro �T�A�#,If)_ - <br /> 1 - ~- W° Product Type: _ % " r. ,. <br /> Total Capacity: '3 S� gallons <br /> (per tank or cumulative far contain r_-1 product type) Install Date: <br /> 'y #of Containers-- Ta#�- --- <br /> ❑ Tank (2820) i Z containers (2821) <br /> 2 Total Capacity: _ J gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (2820) 11Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers byproduct type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: �� gallons Total Capacity for Site: 3�� gallons <br /> Comments: <br /> I <br /> EHD Inspector: Reviewed l Date: Entered Date: <br /> By Initial: 1 It nl %,?K-01 I By Initial: <br /> *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 /> 09/12/08 <br />