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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 /> J' �h/ 6 Page hof <br /> Facility Address: City: Inspecti D <br /> J n <br /> FA M PR M Program Ell <br /> I erd- <br /> � aZ O a Zg <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 contain . <br /> Tank (2820) ElContainers (2821) #of Containers: TA �- $ to <br /> 1 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative nt5iners by product type) <br /> Install Date: /U?,� /'/,q/� D <br /> / #of Containers: TA#: g' <br /> [�KTank (2820) ❑ Containers (2821) <br /> 2 ty: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 3 Total Capacity: t' gallons Product Type: nLA�A! <br /> (per tank or cumulative for contairf rs y product type) Install Date: <br /> Tank (2820) ❑ ners (2821) #of Containers: T #: <br /> 4 Total Capacity: r _gallons Product Type: <br /> (per tank or cumulative for contain rs by product type) Install Date: <br /> T/1"i-ank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for contaiffers by product type) Install Date: T/? <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: <br /> *Aboveground storag6tank 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 /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />