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1 � _ <br /> ` SAN.JOAQUIN COUNTY <br /> J <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: I <br /> �/, �C;J Page of <br /> Facility Address: ,�. _ _ _. City: inspectio n/Da�� <br /> FA#: PR#: Program Elpnent- <br /> D j96ZoV <br /> Tank/Container Information <br /> Complete for all sites With cumulative aboveground storage of petroleum X1,320 gallons in tanks* and containers**. <br /> Complete one box for each tank or each cumulative container product type. <br /> l Tank (2820) I] Containers (2821) #of Containers: TA#: <br /> 10 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 /> 2 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install-Date:- <br /> El <br /> ate:❑ 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 /> ElTank (2820) ElContainers (2821) #of Containers: TA#: <br />` 5 Total Capacity. , gallons Product Type: <br /> I <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> ���✓ Z' /9 <br /> I <br /> i' <br /> l <br /> i <br />{ EHD Inspector: J Reviewed Date: Entered Date: <br /> By initial O.Q� By Initial: `� I <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 />