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: t SAN JOAQUIN COUNTY <br /> 'yr <br /> �JNVIRONMENTAL 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 STfORAGE PROGRAM SURVEY FORM <br /> Facility Name: GI 1 Page �� of <br /> Facility Address: Y Gity: Inspection ate: <br /> R M a Progr m 4m <br /> 1 <br /> 7 <br /> Tank/Contain' nformation <br /> Complete for all sites with cumulative aboveground storage of petroleum x1,320 gallons in tanks*and containers**. <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) ElContainers (2821) #af'Containers:° _ TA#: <br /> F[ x <br /> 1 Product Type: <br /> Total Capacity: gallons <br /> i (per tank or cumulative for co finers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of.Contaitlers: TAM <br /> 2 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for cSfitainers by product type) install Date: <br /> Il. <br /> ❑ Tank (2820) 4containers (2821) #of Containers: TA#: <br /> r <br /> 3 Total Capacity: S gallons Product Type: AI g 1 DIV <br /> i <br /> (per tank or cumulative for containers by product type) Install Date: <br /> r <br /> ElTank (2820) y L.�-Containers (2821) #of Containers: TA#: <br /> 4 _ -_ _ Product Type: <br /> Total Capacity: ,_gallons <br /> (per tank or cumulative for conw,ners oy product type) Install Date: <br /> El Tank (2820) ElContainers (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: f i2 gallons Total Capacity for Site: ��� gallons <br /> Comments: S <br /> EMD Inspector: Reviewed Data: EnteredDate: <br /> By Initial: �.�� By Initial: ke, ��41,�6y <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 IE <br />