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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 /> 7-6 R fA/3/-15 Page of <br /> Facility Address: City: Inspe n Dote. <br /> FA#: PR M Program EI me t: <br /> 2 <br /> X30 <br /> Tank/Container Information <br /> Complete 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 /> ank (2820) ❑ Containers (2821) #of Containers: _TA#: h9 <br /> 1 Product Type: ��c0 <br /> Total Capacity: Z�� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> �nk (2820) ❑ Containers (2821) #of Containers: TAM , 7 <br /> 2 Total Capacity: �� �� Product Type: Y� j E :2 <br /> gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> E/Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Product Type: <br /> Total Capacity: j jl-t/Y� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Dank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Product Type: <br /> Total Capacity: �i�� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) a-Containers (2821) #of Containers: J TA#: �J <br /> 5 -� Product Type: II% �' <br /> Total Capacity: S� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: O is gallons Total Capacity for Site: gallons <br /> Comments: Orr E <br /> Z o o — <br /> EHD Inspector: Reviewed Date: Date: <br /> Entered <br /> By Initial: ���' By Initial: <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. OC <br /> **Container means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> AST SURVEY FORM <br /> 09/12/08/08 <br />