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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 /> Facility Address: City: Inspec'on Dat <br /> �S Z(::, W . 11��S t-I I �+o ti ��-. S oy�-�v� -41,7' 1z_ <br /> FA#: PR M Program Element: ' <br /> l v2 S osa9� <br /> 3'2- <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: <br /> 1 Total Capa . �pproduct <br /> allons Product Type: 2 tit. nl 0 Z 4 <br /> "� <br /> (per or cumulati�for ainers byype) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: _ ,S l g 1 3 <br /> 2 Product Type: �c�r�j S�-e, �� Z, (C l e4l <br /> Total Capacity: Ud U gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 1 1 Tank (2820) ElContainers (2821) #of Containers: TA#: U 51 g j <br /> 3 Product Type: <br /> Total Capacity: (j IOU V gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) Containers (2821) #of Containers: �_ TA#: T� s <br /> 4 Product Type: / �0'C. N U <br /> Total Capacity: � L O gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: _(9,4 1 Q �( 5 <br /> 5Product Type: �1h D / <br /> Total Capacity: � gallons <br /> (per tank or cumulative for containers b product pe) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: /3 on gallons <br /> Comments: BGG i �lJ�T'-wqj <br /> Loy- 57157-1,4- <br /> EHD Inspe or: Reviewed Date: Entered Date: <br /> By Initial: By Initial: hg <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. o <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09112108 <br />