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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.sigov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> Page L of <br /> Facility Address: city: Inspectl to, <br /> /320 o r /Z 0 0 US �Oli T �S Q <br /> FA s: PR M Program Elem t: <br /> / 9 5 '� Zg <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: r- TA#: <br /> 1 Product Type: P� <br /> Total Capacity: 'Z S O gallons <br /> (per tank or cumulative for containers 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 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: RR <br /> Total Capacity this Page: r gallons Total Capacity for Site: 2 J V gallons <br /> Comments: S <br /> Zv <br /> EHD Inspector. ,� Reviewed ' - Date: Entered Date: <br /> By Initial: V A ( I , G1.c By Initial: <br /> `Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of p troleu <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 7 f `" $ , AST SURVEY FORM <br /> 09/12/08 <br />