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4 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.sigov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: _ <br /> L r � Page of <br /> Facility Address: <br /> 1 City: Inspe <br /> Za By v, 8 r <br /> FA#: PR#: Progilam <br /> 0 2 � lp"–d <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks' and containers". <br /> Com I e one box for each tank or each cumulative container product type. <br /> eank (2820) Containers (2821) #of Containers: TrA#: <br /> Total Capacity: <br /> 1 gallons Product Type: Id.l <br /> (per tank or cumulative for con ainers by product type) Install Date: <br /> MTank (2820) ElContainers (2821) #of Containers: #: <br /> 2 Total Capacity: � Product Type: <br /> gallons <br /> (per tank or cumulative for co tamers by product type) Install Date: <br /> 21/Tank (2820) ❑ Containers (2821) #of Containers: TAM <br /> 3 Total Capacity: Z-0-0 gallons Product Type: �� <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 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: '7 gallons Total Capacity for Site: S gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Data: <br /> By Initial: ll, t g-S,0 By Initial: 9 b, <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 2801 ASTSURVEYFORM <br /> 09/12/08 <br />