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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 Nam <br /> Page / of <br /> Facility Address: City: Inspecti D <br /> Z L- L 0 ov fToc%l�y✓ 1710 <br /> FA#: PR M Program Element: <br /> Io53c>79, 2 � 3 C7 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 2_1,320 gallons in tanks' and containers". <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) [I Containers (2821) #of Containers: TA#: <br /> 1 Product Type: au'v�v <br /> . <br /> Total Capacity: A tq t?o gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: _TTAI#: ��i 1 a Das S <br /> 2 Total Capacity: ,�F�fJ gallons Product Type: ' _ <br /> (per tank or cumulative for containers by product type) Install Date: <br /> #of Containers: TA#: a6-1 <br /> iJ Tank (2820) El Containers (2821) <br /> 3 Product Type: � <br /> Total Capacity: �P� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: 02 <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) El Containers (2821) <br /> #of Containers: TA#: <br /> 5 Product Type: <br /> Total Capacity: 3 r�"� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: Q gallons Total Capacity for Site: 1/h-0 gallons <br /> Comments: <br /> a IV D gnhAl <br /> " % <br /> EHD Inspector: Reviewed Date: Entered )J Date: <br /> By Initial: VIA v1.11t- By Initial: <br /> "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. 6 <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />