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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 />11/ <br />Page of f <br />Facility Address: City: <br />Z 7 r0 l C�l,.�� <br />4; <br />Inspec 'onate: <br />C <br />�1 � <br />FA #: <br />% _ <br />PR M <br />0579'7 7 7 <br />Program�q le ent: <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) ElContainers (2821) #of Containers: TA "l g <br />nn <br />1Product <br />Type: <br />Total Capacity: 170 � gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />#of Containers: TA#: Com"ZA <br />3 Tank (2820) ❑ Containers (2821) <br />2Product <br />Type: <br />Total Capacity: s' C) gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />#of Containers: TA#: <br />El Tank(2820) Containers (2821) <br />3 <br />,r- r Product Type: <br />Total Capacity: `� gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />ElTank (2820) t Containers (2821) #of Containers: TA#: <br />4 <br />-- Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative for cont -diners --6y product type) Install Date: <br />r --i <br />�,L-j Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />5 <br />Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />Total Capacity this Page: / gallons Total Capacity for Site: / gallons <br />Comments: <br />EHD Inspector: - <br />Reviewed Date: <br />By Initial: t, ,1_ 0'2� <br />Entered 1 Date: <br />1 By Initial: X/ <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 />09112/08 <br />