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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 /> 0(✓r t p kA" Coq"f Pageof <br /> Facility Address: <br /> r City: Inspection Date: <br /> FA <br /> PR#: (� Program Element: <br /> �7 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks' and containers"". <br /> Com fete one box for each tank or each cumulative container product type. <br /> ,-Ta V( 820) El Containers (2821) #of Containers: TA#: 'ja�o2l <br /> 1 Total Capacity: Jb Product Type: Cgallons G1 � <br /> l�)Z <br /> V�� AO, 3 <br /> (per tank or cumulative for containers by product type) <br /> Install Date: Q <br /> #of Containers <br /> a k <br /> T2820) El Containers (2821) _ TA#: <br /> 2 Total Y Z�(� gallons Capacity: Product Type: _kMO� & -t--CA <br /> P �tC,LLt A& 10CA <br /> D ©) <br /> (per tank or cumulative for containers by product type) <br /> Install Date: _�1/�� r�S <br /> #of Containers: TA#: 02 02 ,� <br /> f� T�hk 2820) ❑ Containers (2821) P"5 � <br /> 3 Product Type: _l�.lAfavj; � <br /> Total Capacity: gallons <br /> (per tank or cumulative for contain s by product type) � � � iy �O� <br /> Install Date: (/11 vl(L�A <br /> � n (2� ❑ Containers (2821) #of Containers: TA#: <br /> 4 Product Type: �lnl-,i1 -I- � � <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) LJ <br /> Install Date: Wa vu, <br /> n (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: AVA ubi G n <br /> (per tank or cumulative for containers by product type) 24 3� n -Z <br /> Install Date: r` <br /> Total Capacity this Page: q30 gallons Total Capacity for Site: <br /> gallons <br /> Comments: <br /> EH D Inspector: �:��By <br /> viewed Date: <br /> Entered Date: <br /> Initial: FK­ I' By Initial: cc <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> 4 <br /> ""`Container means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />