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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 /> r-1--r-1-- .�' �c. a Page of <br /> ' <br /> Facility Address: City: 15$A7 Inspect'o �tq: <br /> rI ' <br /> FA#: /� PR M 0 Progr m <br /> �a 2 7b <br /> Tank/Container Information <br /> Comple 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 /> Eh/Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> V <br /> 1 Total Capacity: -i7 <br /> apacity: / 00 (7 gallons Product Type: J�Q ) <br /> (per tank or cumulative or containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#; $ LZT <br /> 2 Product Type: - <br /> Total Capacity: TrCrdlo gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 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 /> 4 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 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 0 00 gallons Total Capacity for Site: Q gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: ll 1`� p 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 />