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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 /> P OS povier , co P Aoo'j 4Z' Page of <br /> Facility Address: City: Inspec'on Dat : <br /> W , WASW IiJ &+0fJ V—. E'De,r-4bs J L 24310°1 <br /> FA#: PR M Program Element: <br /> lv2 S 9sa90 632 <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#: / 571 43 a-1 2 <br /> 1Product Type: 1 e��. tQ 0 Z <br /> Total Capacity: �bt) gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> [kf Tank (2820) ElContainers (2821) #of Containers: TA#: l2sl $2 <br /> 2 Total Capacity: L4 1 000 gallons Product Type: le-41 l <br /> (per tank or cumulative for containers by product type) Install Date: <br /> yTank (2820) ElContainers (2821) #of Containers: TA#: U S/ g I.l <br /> 3 Total Capacity: OU U gallons Product Type: �y^� -Z. Vic c A <br /> d f <br /> (per tank or cumulative for conta ners by product type) Install Date: <br /> ElTank (2820) Containers (2821) #of Containers: TA#: <br /> 4 Product Type: n I 6&-L, N U <br /> ain <br /> Total Capacity: LO gallons = <br /> (per tank or cumulative for con ers by product type) Install Date: <br /> lj Tank (2820) ❑ Containers (2821) #of Containers: TA#: (9 A5-1 4 2./ t5-- <br /> 5 <br /> 5 Product Type: Dy- 01 L <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: (a 0 0 gallons Total capacity for Site: gallons <br /> Comments: S PGL v �Vy 03 0/1 j <br /> EHD Inspe r: Reviewed Date: Entered Date: <br /> y 0jBy Initial: 1 n �. By Initial: IV <br /> n <br /> *Abovegroundstorage tank means a tank that has the capacity to store 55 gallons or more of petroleum. D` <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> osis 2ioa <br />