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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 /> k p 1 R G ARA Page 2—of ?. <br /> Facility Address: eta: 9 <br /> (J 'OS , <br /> O .�, S (1)� 2/ <br /> itY: Inspec[i nl! a / <br /> FA#: PR#: <br /> &011902 mProgrElement:: <br /> Tank/Container Information g7 <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#: D $ <br /> 1 Total Capacity: 55- <br /> gallons Product Type: ��J (� (f/ <br /> 77 <br /> (per tank or cumulative for containers 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 byproductlype) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Product Type: <br /> Total Capacity: gallons <br /> (per tank orcumulative 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: Reviewed Date: Entered I Date: <br /> By Initial: By Initial: / 'v0 <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 <br /> 09/19/09 AST SURVEY FORM <br />