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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 /> :Page of <br /> Facility Address: Cit <br /> I y Inspection Date: <br /> FA#: e s G �i'uJs G $ <br /> r PR#: o <br /> O Z prog am E!e ent: <br /> CJ Z <br /> Tank/Container information <br /> Complete for all sites with cumulative aboveground storage o(petroleum 21,320 gallons in tanks`and containers". <br /> Com tete one box for each tank or'each cumulative container roduct type. <br /> Jk Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Total Capacity: -Z So gallons Product Type:- <br /> (per tank or cumulative for containers by product type) ' Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Product Type: 1yuj -3c A, cp�,.� <br /> Total Capacity: �o gallons <br /> (per tank or cumulative for containers byproduct type) Install Date: <br /> ,t Tank (2820) ❑ Containers (2821) *of Containers: TAM <br /> 3. a Total Capacity: Product Type: s,(� of 7 <br /> Zara gallons <br /> (per tank or cumulative for containers by product type) Install Date: E <br /> r KI Tank (2820) :❑ Containers (2821)• #of Containers:. TA#: <br /> 4 Total Capacity: 7�r� `gallons -Product Type: <br /> (per tank or cumulative for'containersbyproduct type) Install Date: <br /> ❑ Tank (2820) . g Containers (2821) #of Containers: 57 TA#: <br /> 5. Product Type: <br /> Total Capacity: = Z-75.' gallons <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> Total Capacity this Page: 12,1 -75- gallons Totai Capacity for Site: ��75= gallons <br /> Comments: <br /> EFID inspectReviewed Date: Entered Date: <br /> By.Initial: 1. -['0 By Initial: 1 {y D <br /> v round storage tank means a tank that has the capacity to-store 55.gallons or more of petroleum.! 2S <br /> "Cafitainer means a storage device designed to be.moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />