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' y _ 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 /> rARIAO _ Page_/__ of <br /> Facility Add ss: City: Inspectionate: <br /> s- D . . . A >l p/t. r <br /> FA#: PR#: Program Element: <br /> T <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks`and containers**. <br /> _/ <br /> Complete one box for each tank or each cumulative container product type. <br /> I�7 Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Product Type: <br /> Total Capacity: gallons -• -�-- <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ank (2820) ❑ Containers (2821) #of Contaihers. 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: TA#: <br /> 3 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ElContainers (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 /> ❑ 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 /> EHD Inspector: =eviewed Date: Entered Date: <br /> Initial: VA 'I .fl)�•0 By Initial: D <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 /> EHO 28-01 AST SURVEY FORM <br /> 09117108 <br /> _ rr <br />