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.. - SAN JOAQ6IN COUNTY <br /> YNVIRONMENTAL.HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(208)468-3433 Web:www.sjgov.orglehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> L.�' ti R0 S Page _/_of <br /> Facility Address: City: Inspectio Date- <br /> 0j Z3 <br /> FA#: PR#: Program� <br /> 7IG3a <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum X1,320 gallons in tanks*and containers**. <br /> I. Com tete one box for each tank or each cumulative container product type. <br /> I� <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Total Capacity: gallons Product Type: �,��� <br /> (per tank or cumulative for containers by product type) install Date: <br /> l <br /> ank (2820) [1 Containers (2821) <br /> *of Containers: TA#: <br /> 2 Total Capacity: S"/,t/P gallons Product Type: <br /> (per tank or cumulative for containers by product-type), Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM <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: TAM <br /> 4 Total Capacity: gallons Product Type: <br /> (pertank orcumulative for containers by product type) Install Date: <br /> EJTank (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 /> 1 Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: r Reviewed Date: Entered Date: <br /> By Initial: By Initial: Q <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 /> 08/1 2loa <br />