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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 /> o GNA G Page� of--4— <br /> Facility Address: City: Inspectio Date: <br /> / * 6 � z 6 i /.7T X7/0 <br /> FA#: PR#: Program El nt: <br /> I Z `F �' 65c.'9 3 76 ` <br /> Tank/Container Information <br /> Complete f all sites with cumulative aboveground storage of petroleum ?1,320 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 /> #: <br /> 1 Product Type: [ Fi�SZlli <br /> Total Capacity: U Q gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) C31/ <br /> s (2821) #of Containers: TA <br /> ElC3 <br /> 2 Total Capacity: / gallons Product Type: 9 <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) 19Containers (2821) #of Containers: TA#: <br /> 3Product Type: S X / <br /> Total Capacity: �D gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> #of Containers: TA#: <br /> ❑ Tank (2820) [Containers (282 1) , <br /> 4 Total Capacity: �S gallons Product Type: ��/A �!% Dl L <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: (j gallons Total Capacity for Site: Or gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: ')_'�1- By InRial: <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 />