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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 />L' / X ��� Vii/ <br />Page Of <br />Facility Address: <br />City: <br />Inspectioatt <br />2/J,SS v�� <br />v, <br />l� g <br />FA #: <br />PR If: <br />Progrgg� &ttaal: <br />� 7-0 <br />06-3,:9 <br />3O ?Al <br />UY �1 <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground <br />storage of petroleum 21,320 gallons in <br />tanks` and containers". <br />Complete one box for each tank or each cumulative container product <br />type. <br />21 Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#m <br />1 <br />Total Capacity: � Cgallons <br />Product Type:� <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ <br />#of Containers: to#: <br />Tank (2820) Containers (2821) <br />2Total <br />Capacity: p y 5 U� gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />2 Tank (2820) ElContainers (2821) <br />#of Containers: TA#: <br />3 <br />r-- <br />Total Capacity: S 0-e gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank IJ Containers <br />#of Containers: TA#: <br />a <br />(2820) (2821) <br />4Product <br />Type: /v% 0 /Z -O <br />Total Capacity: ,���.5 gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />El Tank(2820) Containers (2821) <br />#of Containers: TA#: <br />5 <br />Product Type: /71 <br />rl", <br />(-1 <br />Total Capacity: -Ugallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: / % 0 gallons <br />Total Capacity for Site: IbIP <br />gallons <br />Comments: F/x <br />u2o <br />EHD Inspector: TRevievved <br />' <br />Date: <br />Entered <br />Date: <br />y Initial: <br />O Q <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 />09/12108 <br />