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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 /> Facilitymee:: I <br /> V- T i � (?� Page of <br /> % <br /> Facility Address:_ City: Inspection Date: <br /> FA M PR M Program Element: <br /> 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 /> Tank (2820) 11 Containers (2821) #of Containers: ) 11 <br /> TA#: <br /> 1 �I <br /> Total Capacity: oz gallons Product Type: <br /> (per tank or cumulative for cafitainers by product type) Install Date: 0, Al <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: G9 gallons Product Type: 61 <br /> (per tank or cumulative for containers by product type) Install Date: iU <br /> [ Tank (2820) ❑ Containers (2821) #of Containers: TA#: Zc5-;2 bJ <br /> L9 Product Type: Ot <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: %,I 0 <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: _05 aD <br /> 4 Total Capacity: P gallons Product Type: OI <br /> (per tank or cumulative for containers by product type) Install Date: I U <br /> X Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 14,0 5 Total Capacity: 61 gallons Product Type: 6,11 <br /> (per tank or cumulative for containers by product type) Install Date: 1�610 <br /> Total Capacity this Page: X(3 t f-A, gallons Total Capacity for Site: gallons <br /> Comments: t <br /> u Z 2 <br /> EHD Inspector: 1 1, Reviewed Date: Entered Date: <br /> By Initial: 1 ,'IAo By Initial: le'o <br /> *Aboveground sto age 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 />