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11 •• SAN JOAQUIN COUNTY 00 <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 /> ��� A �A) Page / of <br /> Facility Address: Cit : Inspection at <br /> C Iq/v v� T e lolb 0 <br /> FA#: PR#; Program Elenn <br /> o/ 3o S 2.8 � <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 /> #of Containers: TA#: <br /> ank (2820) 11 Containers (2821) <br /> 1Product Type: n .S <br /> Total Capacity: S-06gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 02//Tank (2820) ❑ Containers (2821) #of Containers: T/-A�#: <br /> 2 Product Type: <br /> Total Capacity: �gallons <br /> _O /,,/ <br /> (pertank or cumulative forcontainers by producttype) Install Date: ITA IVA/ -14 rJ <br /> L7 Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Product Type: <br /> Total Capacity: 0-0 gallons <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> El Tank (2820) ©'Containers (2821) #of Containers: ?i TA#: <br /> 4 Total Capacity: //0 gallons Product Type: �/Sf[ ni Q <br /> (per tank or cumulative for containers byproducttype) 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 producttype) Install Date: <br /> Total Capacity this Page: , /.� gallons Total Capacity for Site: gallons <br /> Comments: T/y <br /> 2p 0 � <br /> o/Z <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: 01.0� 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 /> EHD 28-01 - AST SURVEY FORM <br /> 09/12/08 <br />