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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 Name: r / <br /> c) t_r ZZ 1 Page L of <br /> Facility Address: /&C'.75-0 City: InspectiorWat <br /> r Al r- T o <br /> FA�: PR#: Prog m Elerr nt: <br /> i "77- osa �5 z 8 0 <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 /> [J'fank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1Product Type: <br /> Total Capacity: �4� gallons <br /> (per tank or cumulative for containers byproduct type) Install Date: <br /> ff'Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 2Product Type: TZ <br /> Total Capacity: t'o'e') gallons <br /> (per lank or cumulativefor coli finers by type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> p <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: cq-4 gallons Total Capacity for Site: fj J Cl gallons <br /> Comments: <br /> EHD Inspector Reviewed t , .f Date: Entered Date: <br /> C. , <br /> 1/�/� <br /> By initial: LI_g-01 By Initial: HE <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 />