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SAN JOAQUIN COUNTY to <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 /> a 13Page of <br /> Facility <br /> Address: N^O �O �C�y: of Insp�ti n D te: <br /> -/ <br /> FA#: PR�: Program 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 conta,iinnerQproduct type. <br /> Tank (2820) 11 Containers (2821) #of Containers: oar q <br /> 1 Total Capacity: f C) ©Ogallons Product Type: <br /> (per tank or cumulative for containers byproduct type) <br /> �/ Install Date: <br /> L Tank (2820) ❑ Containers (2821) #of Containers: / TA#: 42:i f 102&42 <br /> 2 Total Capacity: �gallons Product Type: G�'Y <br /> (per tank or cumulative for containers byproduct type) Install Date: <br /> El Tank (2820) 5r-Containers (2821) #of Containers: 7 TA#: <br /> 3 Total Capacity: _�! gallons Product Type:'O/2, I <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) I—vContainers (2821) #of Containers: TA#� <br /> 4Total Capacity: l'J' 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: I/ gallons Product Type: IL14! rF <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: 036 19 PI41" <br /> Zo j q — Z/ 6 <br /> EHD Inspector: Reviewed Date: Entered Date <br /> j , By Initial: '010 �,1�, t7 By Initial: 1` of L <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 /> 09/12/08 <br />