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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH'DEPARTMENTe <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. y <br /> 1 � Page of <br /> Facility Address: city: N_ �6Ins <br /> �} -"�■,_N�� �` pection Date; <br /> FA i<t: l 1VlQr PR rogram Ele t: <br /> L <br /> Tank/Container Inflonmation <br /> .Complete for all sites with cumulative aboveground storage of petroleum zt. 320 gallons 1 �ndiners°•. <br /> Complete one box for each tank or each.cumulative container product tyee. <br /> ,Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1rel <br /> Total Capacity:- gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ill'Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Produc L <br /> Total Capacity: <br /> (pe n mer, y product typo) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: r <br /> 3o uct Typt=: <br /> Total Capacity: S� ons <br /> ve or containers by product type) <br /> Install Date: <br /> Tank (2820) ❑ Containers (2821} #of Containers: TA#: rr <br /> 4ype <br /> Total Capacit : ns <br /> mu alive for containers by product type) Install Date: <br /> ❑. Tank (2820) . Containers (2821) #of Containers: TA#: <br /> 1 <br /> 5 Total Capacity: gallons ProductType: _ <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 /> 61 I <br /> nnff'' G Yr <br /> !�!l q�Vft <br /> EHD Inspector: �. Reviewed Date: Entered Date: <br /> By Initial 0�, -� t 0 By Initial: <br /> . . j <br /> "Aboveground storage tan 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 /> END 28-01 <br /> /08 <br /> U9112J08 AST SURVEY FORM <br />