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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 /> LG Page--2— of <br /> Facility Address: <br /> City: <br /> InspectioD te: <br /> 01"n 67 P <br /> FA#. Program Element: <br /> 3 <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) C�Containers (2821) #of Containers: TA#: N5A0/,/v 9 <br /> 1 f�— Product Type: t�S Ca i <br /> Total Capacity: gallons <br /> <br /> - <br /> ❑ Tank (2820) Containers (2821) #of Containers: ___L TA#: AgaDl� tTU <br /> 2 Total Capacity: Product Type: �c7 <br /> <br /> <br /> Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product Type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> Total Capacity this Page: O gallons Total Capacity for Site: 7 1216' gallons <br /> Comments: <br /> EHD nspector: Reviewed Dater Entered Date: <br /> By Initial: I!_. /3 <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. /I� <br /> **Container means a storage device designed to be moved when full. <br /> EHD 2MI <br /> 09/12/06 AST SURVEY FORM <br />