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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 85202-3029 <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 /> C a fia A ilk C [L�o Page of <br /> Facility Addre : City: Inspection D teh <br /> 14/' T <br /> FA#: PR M. Program Element: <br /> -Z <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: TA#: P62-7 IrZe4e <br /> 1 Total Capacity: to d gallons Product Type: A2 z7 <br /> (per tank or cumulative f r containers by product type) <br /> Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: E. TAM, /9�1� '7 <br /> 2 Product Type: zLt2'Pb <br /> Total Capacity: . (2 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) /containers (2821) <br /> #of Containers: TA#: 195)`7'RIo S <br />� - 3 Product Type: <br /> Total Capacity: �[�' gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Ind Containers (2821) #of Containers: TA#: `h 1`7 �o� <br /> 4 Product Type: ���it2 �Gl C! ��"�✓ <br /> I Total Capacity: s gallons <br />" (per tank or cumulative for containers by product We) <br /> �� install Date: <br />{ ❑ Tank 2820 ER/Containers 2821 #of Containers: ,� TA#: <br /> E ) { ? <br />�i <br /> 5 Total Capacity: 1 ® gallons Product Type: /n/A S l E F? f �J <br /> i (per tank or cumulative for containera by product type) Install Date: <br /> Total Capacity this Page: ?2.,0 gallons Total Capacity for Site: gallons <br /> . Comments: <br /> r <br /> LEHDnspector: Reviewed Rate: Entered Date: <br /> . By Initial By Initial: l� <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 2M1 AST SURVEY FORM <br /> Hole ainn - <br />