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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 /> T D G f C "rl l/er T/a�% �Zf Page of_-��___ <br /> Facility Address: City: Inspection D te: <br /> ZS A ! /G � T� tI / 4 <br /> FA#' PIR!�: Program Eirme t: <br /> 3� e6-a?1�16` „ z <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum X1,320 gallons in tanks'and containers". <br /> � <br /> Complete one box for each tank or each cumulative container product type. <br /> 191, Tank (2820) ❑ Containers (2821) #of Containers: STA#: <br /> 1 __-_-� <br /> Total Capacity: foeJ �gallons Product Type: - •-- <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 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 /> 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 /> ElTank (2820) ElContainers (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: 0-0 gallons Total Capacity for Site: gallons <br /> Comments: <br /> z� <br /> EHD Inspector: Revieweda, Date: EnteredjVr Date: <br /> `. <br /> By Initial: A tai- By Initial: <br /> 49 <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 /> i <br /> EHD 28-01 AST SURVEY FORM <br /> 09112!08 <br />