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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 />Page of <br />FacilityAddress: City: <br />A/%N D9 �U56 K 1�- 711 <br />Inspecy�'on Datq <br />�l �� <br />I <br />FA #:R <br />03 l <br />#: <br />050 g� <br />Program Element: <br />_L <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 />Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />1 <br />r Q Product Type: //..(P <br />Total Capacity: 0 gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />2/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 61i612i�5 02 <br />2Total <br />Capacity: Product Type:�� <br />gallons <br />tank <br />(per or cumulative for con ainers by product type) Install Date: <br />/Tank(2820) ❑ Containers (2821) #of Containers: TA#: �� f t?,3/3 <br />3 <br />—6 Product Type: �r_� <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type)Install Date:� Cii//� fid✓ <br />#of Containers: TA#: <br />I'Tank ❑ Containers <br />4 <br />(2820) (2821) <br />..�) Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: L?""; <br />ESXank (2820) ❑ Containers (2821) #of Containers: TA#: <br />5Product <br />Total Capacity: jj_f%''() gallons Type: �` <br />(per tank or cumulative for containers by product type) Install Date: � <br />Total Capacity this Page: (/ 0 gallons <br />Total Capacity for Site: %4 Z� gallons <br />Comments: C tv-/V �/ <br />2 � 6- 0 3 9 <br />EHD Inspector: <br />Reviewed Date: <br />By Initial: \ �.'��, p <br />Entered Date,) <br />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 />