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i <br /> 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 /> X914-nZ Page 2 of 2 <br /> Facility Address: City: Fln=- <br /> 77 <br /> : <br /> 35 S �lu� 99 c�fac� n#: PR M ogram Element: <br /> /� S� 6 2 1 3 8 28 <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: TA#: ,2 Sa/q / (Q�� <br /> 1 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 /> 2 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 /> 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 Total Capacity: Product Type: <br /> p y: gallons <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 /> Total Capacity this Page: 11D gallons Total Capacity for Site: A( gallons <br /> Comments: <br /> # ` <br /> EHD In ctor: Reviewed ,,, Date: Entered Date: <br /> By Initial: � I VI By Initial: <br /> "Abogr nd storage tank m s a tank that has the capacity to store 55 gallons or more of petroleums( T <br /> '"Co or <br /> means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 <br /> AST SURVEY FORM <br />