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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 />0 i3Ii �� p <br />Page -"/— ofy <br />Facility Address:� <br />City: <br />Inspectio D� :�� <br />FA #: <br />M <br />PR #: <br />I DSS <br />Prografn Element: <br />Z K20 <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 <br />product type. <br />U Tank El Containers <br />#of Containers: TA#: � <br />(2820) (2821) <br />1 <br />� <br />Total Capacity: �gallons <br />Product Type: A V 4 <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />ank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />2 <br />Total Capacity: � gallons <br />Product Type: <br />(per tank or cumulative for con ainers by product type) <br />Install Date: <br />#of Containers: TA#: <br />ank42820) ❑ Containers (2821) <br />3 <br />Total Capacity: gallons <br />Product Ty, <br />(per tank or cumulative for con ainers by product type) <br />Install Date: <br />#of Containers: TA#: 661 T� <br />ank (2820) ❑ Containers (2821) <br />4 <br />'7 <br />Total Capacity: gallons <br />Product Type: 4iz��� <br />% <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />5Product <br />Total Capacity: gallons <br />Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: Q <br />gallons <br />Total Capacity for Site: <br />S3 gallons <br />Comments: <br />EHD Inspector: <br />Re viewed Date: <br />By Initial: rj .�� �'i <br />Entered Date: <br />By Initial: B <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 AST SURVEY FORM <br />09/12/08 <br />