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SAN JOAQUIN COUNTY <br /> 'IENVIRONMENTAL 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 /> P P L LA UR G d nI2�Tlr o Page of <br /> Facility Address: City: InspVVP <br /> /6�490A N N �" <br /> FA#: PR M Program Element: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum xl,320 gallons in tanks`and containers*". <br /> Complete one box for each tank or each cumulative container product type. <br /> a/Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Total Capacity: gallons Product Type: L.J'P"-k <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 /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM <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 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 /> Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) I nstail Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: , -Reviewed Date: Entered Date: <br /> 'V I By Initial: 01) �`lj�'t� By Initial: O <br /> `Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. IT <br /> "Container means a storage device designed to be moved when full. <br /> y EHD 28-01 AST SURVEY FORM <br /> 09112108 �� <br />