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J'` 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 /> 0 y C(/&, Page �. of <br /> Facility Address: City: In ti n Date <br /> FA#: PR M Program E ent: <br /> Lfit-93 Z <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks`and containers". <br /> Com Tete one box for each tank or each cumulative container product type. <br /> �ank (2820) ❑ Containers (2821) #of Containers: _ F TA#: <br /> 1 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> I r Tank (2820) T1 Containers (2821) *of Containers: TA#: <br /> 2 Total Capacity: gallons Product Type: f �� <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) ElContainers (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) ❑ 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 /> S Total Capacity: gallons Product Type: <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: Reviewedt Date: Entered Date: <br /> r By Initial: V43 '�,'-77_ By Initial: <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 /> 09!12108 <br />