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SAN JOAQUIN COUNTY <br /> 'x= 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: 17 <br /> l Page of <br /> Facility Address: City: Inspection Dbtel; <br /> /7--D I - G l/ a <br /> FA#: PR#• Program EWAO, t " <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum X1,320 gallons in tanks"and containers". <br /> Com fete one box for each tank or each cumulative container product type. <br /> Tank (2820) ❑ Containers (2821) #of Containers 'TA#: <br /> 1 a 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 Total Capacity: 3.M gallons Product Type: __— <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) I"cantainers (2821) #Of Containers: _/ TA#: <br /> 3 Total Capacity: `" gallons Product Type: G ! <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 11 Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 4 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 /> 5 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: J gallons <br /> Comments: <br /> EHD Inspector. Reviewed Date: =, n Date: <br /> C' By Initial: ".t�. l: 1 D <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 /> 09112ras <br />