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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 e: <br /> NaP A G LA To J'{• E Page / of <br /> Facility Address:20 d /[..� D NCI b. Inspection <br /> FA#: PR#: Program Elelemen : <br /> Z�f223 <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 /> Ef Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Product Type: L �L <br /> Total Capacity: &-0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Vank (2820) ❑ Containers (2821) #of Containers: TAM <br /> 2 Product Type: RYAS <br /> Total Capacity: gallons <br /> (per tank or cumulative for colltainers by product type) 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: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: � '} ;D-J'\ By Initial: It O <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 />