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v SAN JOAQUIN COUNTY VIN„, <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 /> o// L Lh_'SS CRr��d L%6l✓ Rcb Page_/ of / <br /> Facility Address: � City: Inspectl n Date: <br /> Z S. 22o LTon/ /?� a ,✓ "7 o <br /> FA#: PR#: Program Element: <br /> too -z- <br /> Ta klContainer <br /> zzTank/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) ❑ Containers (2821) #of Containers: TA-#: <br /> 1 Total Capacity: Product Type: �. <br /> p y: 3 Z- gallons <br /> (per tank or cumulative for nUZ,by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by producttype) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: 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 Total Capacity: gallons Product Type: <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: �/ gallons Total Capacity for Site: ]i gallons <br /> Comments: <br /> EHD Inspector: L� ,J Reviewed _I Date: Entered Date' <br /> By InH `ial: AIV O� By Initial: !� a <br /> "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more bf 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 />