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Iry <br /> . 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-c' C­,ZT D rj r-ifi F T/�7"D Pj � Page of <br /> Facility Address: <br /> City: Inspection <br /> FA P #: s � Program Element. <br /> 3195 <br /> a <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and-contaihers". <br /> Complete one box for each tank or each cumulative container product type. <br /> ank (2820) ❑ Containers (2821) #of Containers: TA#: n <br /> 1 <br /> Total Capacity: 0'0 gallons Type: L gallons -••- <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820). ❑ Containers (2821) #of Containers: TA#: <br /> 2Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (2820) 1:1Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: u <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <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 /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: Y - p o gallons Total Capacity for Site: S-00 gallons <br /> Comments: <br /> EHD Inspector: Reviewed Dater Entered Date: <br /> / By Initial: to.al. 01 By Initial: i7v <br /> �3 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. . ai <br /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />