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SAN JOAQUIN COUNTY <br />t 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 />A IIJ )5 IrM 0 1V19 C C F,r Al A L <br />Page --L— of / <br />Facility Address: City: <br />Inspection Date: <br />FA #:PR <br />#: � <br />Program Element: <br />2, 3 D <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 />KT Tank (2820) ElContainers (2821) #of Containers: TA#: 57/'R'5`� <br />1Product <br />Total Capacity: l3 U � gallons Type: <br />(per tank or cumulative for containers by product type) Install Date: <br />LVfank (2820) ❑ Containers (2821) #of Containers: TA#: <br />2 <br />T Product Type: <br />Total Capacity: _5 C gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />21 Tank (2820) ❑ Containers (2821) #of Containers: TA#: ItAA�-( o2lp <br />3 <br />Total Capacity: gallons Product Type: <br />(per tank or cumulative for containers by product type) Install Date: <br />#of Containers: TA#: <br />El Tank (2820) Containers (2821) <br />4 <br />.� Product Type:�',/�/� /7 D,2:, 2l V <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />El Tank (2820) El Containers (2821) #of Containers: TA#:� <br />5 <br />Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative for co finers by product type) Install Date: <br />Total Capacity thi Z U allons <br />I Total Capacity for Site: 'j gallons <br />Comments:x. r7 �.. <br />EHD Inspector: <br />Reviewed Date: <br />By Initial: � q,y�Ci� <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 />