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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.Sigov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name- <br /> !A1 G �A�s� Page of - <br /> Facility Address: l O S LA S r , fiI f ,5� A, City: 1nsP�77e�:y <br /> ®J/7/V/, <br /> I FA#: 7 / PR#: Prog�F.L�m <br /> �j �Jr� g 11c�� <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum al,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 <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 /> 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 /> ❑ Tank (2820) ❑ Containers (2821) #of Containers:' TA#: <br /> E <br /> 4 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 /> 8 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: -�>D gallons Total Capacity for Site: gallons <br /> Comments: <br /> r <br /> EHD Inspector: (, Reviewed Date: Entered Date: <br /> By Initial: ii -lc� DO\ 1 . <br /> By Initial: �! <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 /> EHQ 28.01 AST SURVEY FORM <br /> 0911 2105 <br />