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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> VIRONMENTAL 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 Na e: � � PageOf <br /> .8 fim -�- -r <br /> � City: Inspecti Dat <br /> Facility Address: jt <br /> FA#: PR M Program Element: <br /> P.. o 13 C <br /> Tank/Container Information <br /> Complete f r 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 /> al/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 />�4 <br /> Tank (2820) 13Containers (2821} #of Containers: TA#: <br /> 0' <br /> 2 Product Type: ,L <br /> f Total Capacity: gallons <br /> f (per tank or cumulative for containers by product type) <br /> Install Date: <br /> El Tank (2820) ❑ Containers (2821) #o#Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) ElContainers (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 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: ���� <br /> r Total Capacity this Page: �� gallons Total Capacity for Site: 0.6 gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: �7 <br /> By initial: A-1-O� By Initial: pZ at7 B <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 /> 09112/08 <br />