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A SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL-HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 952023029 <br /> Telephone:(209) 468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: g <br /> V6 Z n/ L/_ s` �rj C7 r1A Pae of <br /> Facility Address: City: Inspection pate: <br /> 13 6 13 r te - )wf y Z� G IAIOfAl <br /> FA M PR M Program Element- <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks*and containers`*. <br /> Complete one box for each tank or each cumulative container product type. <br /> ank (2820) ElContainers (2821) #of Containers: TA#: <br /> 1 Product Type: <br /> Total Capacity: / 3 ?� gallons <br /> (per tank or cumulative for containers byproduct type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Ca acit Product Type: ° <br /> p y: gallons . <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 /> R 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> L1Tank (2820) 1:1Containers (2821) #af 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: gallons Total Capacity for Site: �� gallons <br /> Comments: f <br /> h� 4G✓ <br /> "t- Doi I D5 0372— <br /> , <br /> EHD Inspector: Reviewed ` Date: Entered Date: <br /> By Initial: �/(�! t�_�-D� By Initial: <br /> o-fpTf <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 /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />