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SAN JOAQUIN COUNTY W <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 /> l fPage of_� <br /> Facility Address: r city. Inspecdo Dat <br /> 14 <br /> ^ PRS: Program Element: <br /> zn <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 /> Tank (2820) ❑ Containers (2821) #of Containers: TAM Q ��g/a <br /> 1 e:yp <br /> Product T <br /> Total Capacity: 3 � gallons USeh^ <br /> (pertankor cumulative for containers by product type) Install Date: to I''1 <br /> Tank (2820) ❑ Containers (2821) *OfContainers: TA#: .3 <br /> 2 Total Capacity: DU gaitOns Product Type: q t a / <br /> (per tank or cumuisow for tainers by product type) Install Date: 0. <br /> X'Tank (2820) ❑ Containers (2821) #of Containers: <br /> 3 Product T e R� Q 6e <br /> Total Capacity: C3 gallons yp ' <br /> (per tank or cumul i mntelners by product type) Install Date: <br /> f <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: TAM <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: a LJ gallons Total Capacity for Site: -gallons <br /> Comments: <br /> —I T <br /> Ct <br /> rFT 7 <br /> EHD speQo: _ - Reviewed Date, Entered��5� ]Ea <br /> tered <br /> By Initial: - � cv-r-+ Initial:'Above round storage tank means a tank that has the capacity to store 55 gallons or more of peroleu <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 08/12/08 AST SURVEY FORM <br />