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f <br /> SAN JOAQUIN COUNTY <br /> r 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 /> G P'/=- — Page l of <br /> Facility Address: City: Insp&ti Dat . <br /> FA M <br /> j 170 <br /> D L C? �b_3D �z� 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 /> �� <br /> Complete one box for each tank or each cumulative container product type. <br /> L'/ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Product Type: l''� ,� J707Total Capacity: r gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: �1 ale 7 <br /> 2 Product Type: ,90� <br /> Total Capacity: j� (-"-0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) 2q Containers (2821) #of Containers: TA#: <br /> 3 �"S^ Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) f�, Containers (2821) #of Containers: TA#: _ �5 1 Q c (o!' <br /> 4 Total Capacity: 7 gallons Product Type: _ r (/7 �jr G P� <br /> (per tank or cumulative for container's by product type) Install Date: <br /> El Tank (2820) Q"Containers (2821) #of Containers: / TA#: 1 <br /> 5C Product Type: <br /> Total Capacity: .�% gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: -L gallons Total Capacity for Site: 2 S( gallons <br /> Comments: 4,V T1 <br /> Zr 9) 711- 7-7 <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: i�.y, By Initial: g <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 <br /> 09/12/08 AST SURVEY FORM <br />