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SAN JOAQUIN COUNTY `.1 <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:14 <br /> M S Page of <br /> Facility dress: city: Inspectl Date: <br /> S7 3 W- LT j/ G 3 0 <br /> FA C PR#: Prognim Element: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 11,320 gallons in tanks'and containers". <br /> Complete one box for each tank or each cumulative container product type. <br /> D4ank (2820) ElContainers (2821) #of Containers: TA#: <br /> 1 Total Capacity: 1O d gallons Product Type: �lq--F <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <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) Install Date: <br /> Total Capacity this Page: r gauons Total Capacity for Site: �J gallons <br /> Comments: <1 <br /> Zo - / <br /> J � <br /> EHD Inspector: ,r; Reviewed Date: Entered Date: <br /> By Initial: I D- By Initial: O <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 /> 09112!08 <br />