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1 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> 1 ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Nam <br />{ �tJ I Page ( of <br /> Facility Address: C Inspection Date:-1 Huo IKF <br /> � & <br /> FA#: � O� PR#: ..Program�ement: <br /> a Z -w <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 />{ C1Tank (2820) Containers (2821) <br /> #of Containers: t TA#: <br /> 1 <br />� Total Capacity: �gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> I <br /> ❑ Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> �I 2 Total Capacity: gallons Product Type: <br /> 4 (per tank or cumulative for containers by product type) <br /> Install Date: <br /> I <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for-containers by product type) Install Date: <br /> ElTank.(2820) ❑ Containers (2821) #af Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> i <br /> i <br /> t <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 /> 3 <br /> t Total Capacity this Page: gallons Total capacity for Site: gallons <br /> I Comments: <br /> a EHD pector: , + Reviewed Date: Entered Date: <br /> d� �� By Initial:- J L .��.°°1 8y Initial: <br /> "Above ound 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 /> 08/12/08 <br />