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1 SAN JOAQUIN COUNTY MOW <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 <br /> ,, Page of <br /> Facility Address: City: Ins a: <br /> FA A: PR M: Program E erne <br /> S9S" P�06501cP2i <br /> Tank/Container Information <br /> Complete or 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 Totalpacify: gallons <br /> SProduct Type: <br /> ,3 D <br /> (per 7* <br /> o or cumulative for containers by product type) Install Date: <br /> Tank (2820) I, ^nntninem (2821) #of Containers: TAM <br /> 2 5-00 Product Type: -,;y <br /> Total Capacity: _ yauvtw <br /> (per tank or cumulative for containers by product type) Install Date: <br /> � � #of Containers: TAML1Tank (2820) L�IContainers (2821) <br /> 3 Total Capacity: -Sr gallons Product Type: sTk /9/11 <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: TAM <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 1719 gallons Total Capacity for Site: gallons <br /> Comments: " <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: \)A By Initial: -7 <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 />