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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 /> C� Page 2 of <br /> Facility Address: <br /> �G r ^` I ��y I ��-eoV t Inspection Date:: <br /> FA M <br /> 0 <br /> Program Element: <br /> 04;2 S &7i3 z) <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 /> Taft 2820) EDContainers (2821) #of Containers: TA#: �Ar R <br /> 1 <br /> Total Capacity: Product Type: ;G -- d,Q q lS) <br /> Q gallons <br /> (per tank or cumulative for containers by product type) w, �()_ <br /> �,�p�Y Install Date: �,(,r/vt <br /> �LAI <br /> I ankf I (2820) ❑ Containers (2821) #of Containers: T TA#: o <br /> 2 Product Type: vt�.f(,�,t7a,u.�,iC, 4'Gt P1jr 6)�- <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) 350 <br /> Install Date: _Vlil�1(�jtt 2 (,{,�; gin <br /> j2 an (�0) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Product Type: <br /> Total Capacity: 0gallons � <br /> (per tank or cumulative for containers by product type) Install Date: -v�l(��E.�/14 �1✓t t L 3� <br /> lam/ <br /> ank (�) El Containers (2821)j� <br /> #of Containers: TA#: <br /> 4 Product Type: 1AAAKP jA , <br /> Total Capacity: 136 gallons <br /> (per tank or cumulative for containers by product type) Install Date: ''V 1-2- QRV <br /> VLL <br /> at ( 820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: V gallons Product Type: ( 1 i L -P q�/2 r- L <br /> (per tank or cumulative for containers by product type) I <br /> Install Date: <br /> Total Capacity this Page: 5_7 gallons Total Capacity for Site: <br /> gallons <br /> Comments: 10 <br /> EHD Inspector: <br /> Tievved Date: Entered <br /> nitial:2�ai 21 C� By Initial: Date: <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 <br /> 09/12/08 AST SURVEY FORM <br />