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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 /> 7` � , . S' Page / of . <br /> Facility Address: City: Inspecti n Dat <br /> 2 o3 � ia,' �g <br /> FA#: ��ry D v PR#: � Program E1eme <br /> Ci rL��®Q <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#: <br /> 1 Product Type: rA S � -- <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) -Install Date: <br /> 55/Tank (2820) ElContainers (2821) #o#Containers: _ TnA#: <br /> 2 Product Type: r7a�Qom/ <br /> : <br /> Total Capacity: X10 gallons <br /> i p Y <br /> per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 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 /> 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) <br /> Install Date: <br /> Total Capacity this Page: �, gallons Total Capacity for Site: 1451-0-0 gallons <br /> Comments: <br /> Al <br /> EHD Inspector: Reviewed ` Date: Entered Date: <br /> By Initial: v/13 r'�j�-� By Initial: d T <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 /> EHO 28-01 E AST SURVEY FORM <br /> 09/12/08 F <br />