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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: <br />04l <br />0 <br />F" C Gr n <br />Page of <br />Facility Address: <br />City: <br />�rl a ���� <br />Inspection te: <br />%z /zro <br />FA #: O� <br />PR #: <br />Program Element: <br />2L15 -z- <br />Tank/Container <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 />El Tank (2820) <br />IGontainers (2821) #of Containers:. L+ I TA#: <br />1Product <br />To: :taDR,apacity: <br />gallons >i'µs Type: <br />(per tank or cumulative for containers by product type) Install Date: (A11 190 UV A <br />❑ Tank (2820) <br />❑ Containers (2821) #of Containers: TA#: <br />2 <br />Total Capacity: <br />Product Type: <br />gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />❑ Tank (2820) <br />❑ Containers (2821) #of Containers: TA#: <br />3 <br />Total Capacity: <br />Product Type: <br />gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />❑ Tank (2820) <br />❑ Containers (2821) #of Containers: TA#: <br />4 <br />Total Capacity: <br />Product Type: <br />gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />❑ Tank (2820) <br />❑ Containers (2821) #of Containers: TA#: <br />5 <br />Total Capacity: <br />Product Type: <br />gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />Total Capacity this Page: <br />gallons <br />Total Capacity for Site: I U gallons <br />Comments: <br />EHD Inspector:Reviewed <br />- <br />Date: <br />By Initial: <br />Entered Date: <br />By Initial: <br />r,00vegrouna storage ianK meansa tanK tnat 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 <br />AST SURVEY FORM <br />osis �/08 roa <br />