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• • SAN JOAQUIN COUNTY • <br /> 4 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: /� r- / <br /> Won A91DGE WIN��y Page _ of <br /> Facility Address: �„ city. Insp��i � f :D <br /> 59 56 e/ood � ► 1� 6 is <br /> FA#: PR M Program Eleme t: <br /> Tank/Container Information <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 /> 1?' ank (2820) ❑ Containers (2821) #of Containers: TAM 0,,17f 75'9-2- <br /> 1Product Type: 61-'14 s, g 7 <br /> Total Capacity: .Zoo gallons <br /> (pertankor cumulative for containers byproduct type) Install Date: <br /> #of Containers: TAM D 76-93 <br /> Cf Tank (2820) El Containers (2821) 51 <br /> 2 Product Type: <br /> Total Capacity: 5 y o gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Contai,cors. TA#: <br /> 3Product Type: S J 0/ <br /> Total Capacity: 330 gallons <br /> (per tank or cumulative_for c nt�ainers by product type) Install Date: <br /> El Tank (2820) L'd Containers (2821) #of Containers: TA#: <br /> { Product Type: `>�0 y L Nic <br /> 4 Total Capacity: S J gallons y <br /> (per tank or cum ulativefor containersby product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: �_ TA#: l <br /> 5 ' Z" gallons Product Type: �Y D/t !� LLC/ <br /> Total Capacity: ./ ,S <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: / gallons <br /> Comments: <br /> EHD Inspector: Reviewed ^' Date: Entered Date: <br /> ` 4 �[ <br /> By Initial: � I`,al_0By Initial: / I p?7 <br /> *Aboveground!stTrage 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 /> AST SURVEY FORM <br /> EHD 28-01 <br /> 09/12/08 <br />