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1 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 e—of <br /> Facility Address: City: Inspectlo Date, <br /> FAM <br /> PR#: Program Elernent: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 2:1,320 gallons in tanks'and containers". <br /> Complete one box for each tank or each cumulative container eroduct ty2e. <br /> bf�Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Total Capacity: _100 _gallons Product Type; _�,��( � <br /> (per tank or cumulative for containers by product type) Install Date: <br /> K Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2Product Type: <br /> Total Capacity: 10 0 gallons - •• .— <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 ' <br /> Total Capacity: 0 0 gallons Product Type: -D2:LnSYY2.1 SQ _ -E)i <br /> (per tank or cumulative for containers by product type) Install Date: <br /> . Tank (2820) ❑ Containers (2821) #of Containers: TA#: oZ <br /> 4 Product Type: S �' <br /> Tota! Capacity: . ��(� gallons K4 W <br /> (per tank or cumulative for containers by product type) Install Date: <br /> )6-Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> $ Total Capacity: 96'7D gallons Product Type: `L Di.,� <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: &2-0 gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspe Reviewed Date: Entered Date: <br /> By Initial: By Initial: 17LL a <br /> "Abovegr norage tank means a tank that has the capacity to store 55 gallons or more of id'troletim- (ho <br /> . <br /> "*Contain eans a storage device designed to be moved when full. <br /> EHO 28.01 <br /> 09/12/08 AST SURVEY FORM <br />