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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 /> I'�, �. S'O G xti2/ Page _,L, of <br /> Facility Address: City: Inspect n D te: <br /> 2-6 p <br /> FA#:� � � �� � PR# Pro� �em nt: <br /> 66,30 <br /> i LID <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 product type. <br /> Tank (2820) ❑ Containers (2821) #of Containers: 'TA#: <br /> 1 Total Capacity: gallons Product Type: <br /> (per tank or cumulative far ainers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Product Type: � <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (2820) f Containers (2821) #of Containers: _ l TA#: <br /> 3 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 /> 4 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 /> 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: <br /> 3 <br /> EHD Inspector: Reviewed 1Ai01 Date: Entered Dale: <br /> l r By Initial: "I By Initial: <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 />