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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 />�U� �� S <br />Page ` of <br />Facility Address: City: <br />v <br />Inspectionpate: <br />FA #: <br />//W 6 <br />PR #: <br />�4 <br />Program Elginent: <br />-�-� <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 />D Tank (2820) ❑Containers (2821) #of Containers: TA#: <br />1 <br />p� <br />Product Type: <br />Total Capacity: % O ren gallons yp <br />(per tank or cumulative for containers by product type) Install Date: <br />#of Containers: TA#: <br />a//Tank (2820) O Containers (2821) <br />2 <br />r j",l Product Type: <br />J Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />#of Containers: TA#: <br />D` Tank (2820) ElContainers (2821) <br />37rT� <br />Product Type: �_Wz <br />� `� <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />Tank (2820) ElContainers (2821) #of Containers: TA#: <br />4 <br />� � Product Type: / p?� <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />Tank (2820) O Containers (2821) #of Containers: TAM s-stE42 <br />5 <br />- Product T <br />Total Capacity: S C� gallons ype <br />(per tank or cumulative for containers by product type) Install Date: <br />Total Capacity this Page:30 d c) gallons <br />Total Capacity for Site: 3 7_('�(� gallons <br />Comments: <br />EHD Inspector: <br />Reviewed Date: <br />By Initial: <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 />