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U 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: /J ' <br /> C D CTE 57.0L/q lQ 1 Wage .�.of <br /> Facility Address: City: Inspecti n 7/0 <br /> 7 -Af- Gl<T r,� 1 <br /> FA#: PR M. Progratn Ele ent: <br /> Z 3 D5r:3o2• <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum ?1,320 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 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> E�- fank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: �S� gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Tota! 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 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 />+ 5 Product Type: <br /> Total Capacity: gallons <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 /> EMD Inspector: Reviewed Date: Entered Date: <br /> By Initial: '}•�• By Initial: <br /> Aboveground storage tank means a tank that has th61capacity 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 />