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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 /> Page _of <br /> Facility Address: ) t city: Inspe ti Data- <br /> FA <br /> a <br /> � l d <br /> FA#: PR#: Progra Elr <br /> Z D5<3o3$ � 15 <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#: <br /> 1 Total Capacity: S 0.6 gallons Product Type: . <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: kTA#: <br /> 2Product Type: <br /> Total Capacity: O-?' gallons <br /> (per tank or cumulative for containers by product type) Install Dat . <br /> El Tank (2820) C21n�ontainers (2821) #of Contaits: TA#: <br /> 3 Total Capacity: / Oe) gallons Product Type �yA- <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) C containers (2821) #of Containers: TA#: <br /> 4 Total Capacity: r� gallons Product Type: /-/4I%/= 6< �/ <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: / 600 gallons Total Capacity for Site: l 0ifS gallons <br /> Comments: <br /> S : TTS <br /> 12 70 <br /> S � <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> L' By Initial: "�.'>1 -� By initial: j �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 /> 09/12/08 <br />