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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 STORAGEIPROGRAM SURVEY°FORM <br /> Facility Name: <br /> C lJ G 1� e Y Page _Z of <br /> Facility Address: City: Inspe do Date: <br /> 613 I: M ),1�, 12r.0 57 .0 <br /> FA#: PR#: Program Element: <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 tXpe. <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA <br /> 1 <br /> Total Capacity: 0 i) gallons Product Type: <br /> (per tank or cumulative for antainers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821-) #of Containers: TA#: <br /> 2 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 /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> r ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 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 Sit e: FuV <br /> gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date:_ <br /> By Initial: (� (� n By Initial: sJ . C 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 /> EHO 28.01 AST SURVEY FORM <br /> 091121o8 <br />