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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 FORlilif <br />Facility Name: �,/ <br />�j��jjkt NNt� ( <br />Page _ of <br />Facility Address: City: <br />LAI <br />Inspecjj��',on D�te: <br />_G.�-( 7to <br />FA #: PR #: <br />Program Element: <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 />j Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />1 <br />� Product Type:' <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />2 <br />ElTank (2820) El Contain' � # rs: TA#:� <br />Product Type: <br />Total Capacity: (�� gallons <br />(per tank or cumulaGv or containers by product type) Install Date: <br />_- <br />#o Containers: TA#: S/004 <br />El Tank I <br />Tank (2820) Containers (2821) _— <br />Total Capacity: _-:..gallons -ko-duct Type: <br />(per tank or cumulative for containers by product type) Install Date: <br />- <br />— - - -__:�\\Iz 3i�_ <br />4 <br />El Tank 2820 El Containers 282����v � _ ._ # f Containers TA ' 1 <br />l <br />Total Capacity: �� _ gallons oduct Type.1 e� <br />(per tank or cumulative for{�containers by-product type) VV <br />Install Date: �> <br />_ �iL�•E�,� � 1 � <br />__ .__ice' C.:ti ors Si .. �.1 <br />#of qn TA#: �S,5-1) <br />El Tank (2820) ElContainer�(2821) \ e — <br />5 <br />�N��� roduct Type:i <br />Total Capacity: Ballo <br />(per talk r cumulative f r ontainer Oct type) <br />k mr S ilk Install Date: <br />Total Capacity this Page: gallons Total Capacity for Site:-illons <br />Comments: <br />-/l <br />EHD Inspector:Revieed Date: Entered ` Date- r <br />d Byw <br />Initial: �� i (� i 3 By Initial: <br />1{ <br />Aboveground swlage ianK 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 <br />AST SURVEY FORM <br />09/12/08/08 <br />