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Aft <br />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 />�� <br />_1 <br />Facility Address: f/ City: <br />Inspection Date: <br />lizvyIT <br />/,0 <br />FA #: <br />PR M <br />Program EI ment: <br />RipZ <br />F3 <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 />a Tank (2820) ❑ Containers (2821) #of Containers ( TA* z9 ) gCeg0) <br />1 <br />Total Capacity: .� � gallons Product Type: a.,��-�J <br />(per tank or cumulative for containers by product type) Install Date: <br />,1 ank (2820) ❑ Containers (2821) #of Containers: TA#: (56- / $&$ / <br />2 <br />Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative fo ontainers by product type) Install Date: f� ivs <br />ank (2820)ElContainers (2821) #of Containers: TA#: F -Z <br />3 <br />Total Capacity: O 0 gallons Product Type:p� <br />(per tank or cumulative for containers by product type) Install Date: <br />Er Tank (2820) El Containers (2821) #of Containers: v A#: �y l $ L�� <br />4 <br />Product Type:��Q� <br />Total Capacity: 77) gallons <br />(per tank or cumulative for co ainers by product type) Install Date: <br />❑ Tank (2820) Containers (2821) #of Containers: T #: ©� I <br />/ <br />11- <br />5 <br />Product Type: <br />Total Capacity:Z (14 <br />S' gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />Total Capacity this Page: gallons <br />Total Capacity for Site: gallons <br />Comments:' <br />EHD Inspector: <br />Reviewed Date: <br />By Initial: �j'� <br />Entered Date: <br />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 AST SURVEY FORM <br />09/12/08 <br />