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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 <br /> 0 f i D WCC /'Z Page of <br /> Facility Address: City: Inspectio Date: <br /> op <br /> FA#: PR#: <br /> 7-1 <br /> Progra EleEi' <br /> t- <br /> 0611306210 <br /> 0S�Cp D �j'Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks` and *. <br /> Com le "one box for each tank or each cumulative con finer product type. <br /> ❑ Tank (2820) Containers (2821) #of Containers: TA#: <br /> 1 Total Capacity: gallons Product Type: /�� C i '� 01� L� <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) fb�Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: gallons Product Type- /C—) <br /> (per tank or cumulative for co tainers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: 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 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 Product Type: <br /> Total Capacity: gallons <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 /> EHD Inspector: 1- Reviewed Date: Entered Date: <br /> By Initial: By Initial: <br /> `Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. 4� <br /> —Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />