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_ *wi 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 Na e: Page of <br /> ,T'q G e y <br /> Facility Address: City. __ II Inspectioe: <br /> 9 D Q <br /> /S O A/ DUNGAW � ' �N 97 <br /> FA p: J 7 � PR q: Program F,jgrrtegL� <br /> J `l O - .7 �U7r f,J,v77 <br /> Tank/Container Information <br /> CompI to 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 /> Tank (2820) ❑ Containers (2821) #of Containers: T #: <br /> 1 Total Capacity: Cs0 gallons Product Type: DA/) i; <br /> J <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: �c <br /> Total Capacity this Page: J—� gallons Total Capacity for Site: b� J v-r� gallons <br /> Comments: 6 2 0? I 6L, <br /> EHD Inspector �7 Reviewed Date: 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 bf petroleum. <br /> "Container means a storage device designed to be moved when full. <br /> .EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />