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SAN JOAQUIN COUNTY <br /> TNVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> relephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: r ,� 1 <br /> byi V a Page 1 of f <br /> Facility AddrQs boo <br /> oo cz �fb(6v k n City: 1nsttion Date: <br /> F PR# � Program le <br /> 2-- <br /> TanklContainer 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 ty2e <br /> Tank (2820) ❑ Containers (2821) #of Containers: I "TSA#: <br /> 1 Total Capacity: COD Product Type: wt,�tK-� X71 P <br /> p y: gallons <br /> (per tank or cumulative for containers by product type) Install Date: ✓ J <br /> 0 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 /> El Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by 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: I gallons Total Capacity for Site: gallons <br /> Comments: <br /> EH I spe or: Reviewed Date: Entered Dat LV <br /> � � By Initial: t , t .b �� By lnitial: <br /> `Aboveground storage to eans 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 /> 09/12108 <br />