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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 /> kJ•,�f, P,Vu� Page 1 of <br /> Facility Address: City: Inspection Date: <br /> L l�-�,�I�,�► i (.,fit ��?�t� �-Z�-c6 <br /> FA#: PR#: Program Element: <br /> �577'?M ?,31 <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) El Containers (2821) *of Containers: _ TA#: 0 �Il0`7Y4 <br /> r <br /> 1 r—�1�,1 Product Type: r <br /> Total Capacity: � gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> V' Tank (2820) ❑ Containers (2821) #of Containers: �YA TA#: <br /> 2Product Type: -0 <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> l.d'`Tank (2820) ❑ Containers (2821) #of Containers: A- TA#: OS106G <br /> 3 Product Type: t. � 6"1 <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ZTank (2820) ❑ Containers (2821) #of Containers: TA#: U S l Of <br /> 4 Product Type: U t <br /> Total Capacity: 116 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> X Tank (2820) ❑ Containers (2821) #of Containers: N A TA#: 0 S- I L-TE <br /> 5 �Y (: <br /> Total Capacity: 7 � gallons Product Type: i. <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: , "Y`� gallons Total Capacity for Site: gallons <br /> Comments: U m F d A% <br /> EHD Inspector: Reviewed Date: [ fl Entered Date: <br /> By Initial: `7I v,'L 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 />