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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: nn <br /> M i v�� Ge)w Page of <br /> Facility Address: City: Inspection Date:- <br /> 3 - 1'1t� CGU <br /> FA#: I /0q PR#: — Prog/�;/ le ent:_a, <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 /> �l Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 CT�ovPtal-Ca acity: S-26 gallons Type: a ol <br /> r tank r cumulative for containers by product type) Install Date: <br /> [� Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2Toacity: �'o(J gallons Product Type: SGJ-3o �► <br /> (per tan cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) gContainers (2821) #of Containers: i TA#: <br /> 3 Total Cap@ i gallons Product Type: rl t t <br /> (per tank o umulativ -ibr containers by product type) Install Date: <br /> ❑ Tank (2820) �4 Containers (2821) #of Containers: TA#: <br /> 4 Total Capacitulay. SJ gallons Product Type: /- 20 <br /> (per tank or c tiv or containers by product type) Install Date.- <br /> 0 <br /> ate:❑ Tank (2820) 9 Containers (2821) #of Containers: TA#: <br /> 5Product Type: <br /> Total Capacity: 5� gallons <br /> (per tank or umu a for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: `7 Z6 gallons <br /> Comments: A5f k <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> A, By Initial: 1 �1 1l0'tU By Initial: <br /> "Aboveground storage 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 <br /> 09/12/08 <br /> AST SURVEY FORM <br />