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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 /> Page of <br /> Facility Address: City: ins 40ment: <br /> : <br /> I BD � / Z110 <br /> FA#: PR#: Progra <br /> `� r � 2( [ � <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 eroduct tXRe. <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: D <br /> 1Product Type: �I, Lz <br /> Total Capacity: b p0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ,Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: :ZOOO gallons Product Type:a�i 19 <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> Tank (2820) El Containers (2821) #of Containers: TA#: <br /> 3 Product T e <br /> Total Capacity: 4-00 _gallons yp ' <br /> (per tank or cumulative for containers by product typo) Install Date: <br /> Tank (2820) 11 Containers (2821) <br /> #of Containers: TA#: B <br /> 4 Product Type: O� <br /> Total Capacity: 1!500 gallons <br /> (per tank or cumulative for containers byproduct type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: 19 $� <br /> 5 Total Capacity: 10 0 gallons Product Type: OLA-ffU `I <br /> (per tank or cumulative for containers by product type) Install Date: `T <br /> Total Capacity this Page: (a00 O gallonsTotal Capacity for Site: g`1 gallons <br /> Comments: t; &LAn C)O <br /> EMD Inspect Reviewed Date: Entered Date: <br /> By Initial, -j"1�to By Initial: 7 1�)D <br /> vegro orage tank me s a tank that has the capacity to store 55 gallons or more of petroleu . l <br /> "Contain Bans a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/17/08 AST SURVEY FORM <br />