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SAN JOAQUIN COUNTY <br /> NVIRONMENTAL 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 /> V r UG IGj Page 2.of Z <br /> Facility Address: e�� '�J_ ��U� City: Inspect n ate:Kj, <br /> FA#: PR#:6 / ProgL Element: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 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: 1 TA#: /,-5-1 <br /> 1 Total Capacity: ��gallons Product Type: %% ecS�ll e- LL <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 orcumulative for containers by product type) Install Date: <br /> ❑ 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 /> ❑ 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 Inspecto Reviewed Date: Entered Date: <br /> By Initial: By Initial: 1,2 <br /> *Aboveground stor ge 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 /> 09/12/08 <br />