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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> FaCilit Name: <br /> I AAA CA Page of,-)- <br /> Fa r City: Ins n Date: <br /> 3 S -30 <br /> FA#: � � PR#: Prograrrr Ele en <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) p L�)Containers (2821) #of Containers: o 1_, ' TAM <br /> 1 Total Capacity: gallons Product Type: W � clay-1 <br /> (per tank or cumulative for containers product type) Install Date: <br /> [[[Tank(2820) 4 Containers(2821) #of Containers: TAM <br /> 2 Product Type: <br /> Total Capacity: _ gallons <br /> (per tank orcumulativeforcon niers yproducttype) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) <br /> #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: 7j U gallons Total Capacity for Site: gallons <br /> Comments: �Z 00 <br /> '-'lJ <br /> EHD Inspector: 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. <br /> "Container means a storage device designed to be moved when full. <br /> EHD28-01 REV04119112 AST SURVEY FORM <br />