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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 />/✓/-/ v �, <br />Page of -_ <br />Facility Address: City: <br />Inspection Date: <br />FA #: � � 7 � <br />J <br />PR #: <br />Program lemena <br />3 <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks* and containers**. <br />Complete one box for each tank or each cumulative container product type. <br />Tank (2820) ❑ Containers (2821) #of Containers: TA#: 6-1 CA ,3 49 <br />1 <br />2 • Product Type: //� S 6� Ov <br />Total Capacity: � 5'6 gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />2 <br />Total Capacity: gallons Product Type: <br />(per tank or cumulative for containers by product type) Install Date: <br />❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />3 <br />Total Capacity: gallons Product Type: <br />(per tank or cumulative for containers by product type) Install Date: <br />❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />4 <br />Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />5 <br />Total Capacity: gallons Product Type: <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 />J� <br />Reviewed Date: <br />By Initial: <br />Entered Dat�// <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 />0911 2108 <br />