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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: �JZ <br /> A F a Page of <br /> Facility Address: �. City: Inspec ion,atg: <br /> FA#: PR#: Program Element: <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) b'G/ontainers (2821) #of Containers: j - -T�A�#: l <br /> 1Total Capacity:p y: gallons Product Type: <br /> (per tank or cumulative for contai "ers 'y product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Product Type: z J(CJ <br /> Total Capacity: —z gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total y: gallons Capacity: Product Type: <br /> p <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: % O gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: L j Reviewed Date: Entered Date: <br /> By Initial: By Initial: <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 /> ogii 2roR <br />