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R 4^ <br /> 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 /> b AzS` Page of <br /> Facility A dress: > City: Inspectio Da f <br /> O (V - Z" U <br /> FA#: PRM Progra Ei7Fe :0 <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 /> �ank (2820) L1 Containers (2821) #af Containers: TA#: <br /> 1 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> LYTank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2Product Type: d <br /> Total Capacity: S �-0 gallons <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: Product.Type: <br /> p y: gallans <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 /> 13 Tank (2820) ElContainers (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: � � gallons Total Capacity for Site: d gallons <br /> Comments: --r. - <br /> EHD Inspector: Reviewed Date: Entered Dale: <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 /> 09/12/08 <br />