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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 /> C.oc--,. — Page t of�_ <br /> Facility Address: CInspection Date: <br /> FA#. PR M Program Element: <br /> r _J X53 9 o <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 Product Type: 4D �.l <br /> Total Capacity: `�o o gallons <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Product Type: A T� <br /> Total Capacity: /po gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Total y: /0o gallons <br /> Capacity: Product Type: 90 LJ o I <br /> p <br /> (per lank or cumulative for containers by product type) <br /> Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Product Type: t x5,11'— <br /> Total Capacity: —5 p o gallons <br /> (per tank or cumulative fpr containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: ci>' O c) gallons Total Capacity for Site: g� gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: <br /> By Initial: Entered Date: <br /> By Initial: <br /> `Abovegro d storage tank means a tank that has the capacity to store 55 gallons or more df 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 />