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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> < 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <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 /> Facility Address: City: L Inspection Date: <br /> FA#: PR#: Progra rE—Ie-r7Went: <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 /> Pf Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Product Type: �Gr.�l� f�i( jr.,�) j✓j ,;,.� <br /> Total Capacity: r ZO gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> [ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Product Type: �„�Q.���c, c�► l-- ��b�/''�GNjrG� <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 /> 3 Product Type: lle- �;�� �� � � / <br /> Total Capacity: 0 gallons yp ,�7 ��w 1�*—r��'l -7—rA <br /> (per tank or cumulative for containers by product type) Install Date: <br /> dTank (2820) ❑ Containers (2821) #of Containers: TA#: �, 1 <br /> 4 Product Type: ?ice — n� 61., a�e.�c�zTv✓ <br /> Total Capacity: gallons <br /> (per tank or cumulative for contain rs by product type) Install Date: <br /> [Tank(2820) F] Containers (2821) #of Containers: TA#: <br /> 5 Product Type: <br /> Total Capacity: y gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 67, gallons Total Capacity for Site: U gallons <br /> Comments: <br /> p 8�WI3 <br /> EHD spec r: Reviewed Date: Entered Date: <br /> By Initial: By Initial: <br /> w <br /> eground 6orage 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 REV 04/19/12 AST SURVEY FORM <br />