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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 /> r) SS Page_ of <br /> Facility A00rinnit Cit <br /> L <br /> � Ckt t �y_ Inspection D) <br /> Program�lgm <br /> Tank/Container Information Ll <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 /> �D'Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Total Capacity: !S gallons Product Type: '30 W'b& <br /> (pertank or cumulative for containers byproducttype) Install Date: G'`t' 44 GIVIr <br /> 1;2- `fank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: -IS gallons Product Type: lye{ <br /> (per tank or cumulative for containers by product type) Install Date: ' trucK-v <br /> Arank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3e:Product Type: �� ,n, r, <br /> Total Capacity: 1.��' gallons �1 l,, r. <br /> (per tank or cumulative for containers by product type) Install Date: (.eZ.,Lh-m. '`l'tA(, vv% <br /> ,Z Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Total Capacity: Z gallons Product Type: I V— —4D <br /> (per tank or cumulative for containers byproduct type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: '2-:-ZS gallons Product Type: Mt—(4e, C9 I p <br /> (pertank orcumulative forcontainers by producttype) �G�;.67Qvt; Sln(,M <br /> Install Date: A <br /> Total Capacity this Page: ���� gallons Total Capacity for Site: I gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> I By Initial: By Initial: <br /> 'Ab ov un 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 <br /> 09/12/08 AST SURVEY FORM <br />