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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 Na <br /> J �� LAJ Page of <br /> Fac Add s: qq City Q Inspection Date: <br /> FA#: PR#: Progir'"� ent: <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 /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: ��1 q1l 79 <br /> 1 IProduct Type: S� p1' <br /> Total Capacity: gallons <br /> (pe tan r cumulative for containers by product type) Install Date: <br /> [� Tank (2820) ❑ Containers (2821) #of Containers: TA#: DSI R 4? <br /> 2 (� Product Type: �Jd 41 <br /> Total Capacity: gallons <br /> (per(gor cumulative for containers by product type) Install Date: <br /> E1 Tank (2820) ❑ Containers (2821) #of Containers: ' TA#: �l <br /> 3 Tota `� Product Type: <br /> l Capacity: gallons <br /> (pe tank cumulative for containers by product type) Install Date: <br /> Eg' Tank (2820) ❑ Containers (2821) #of Containers: TA#: Dc5 ! 02 <br /> 4Product Type: OI <br /> Total Capacity: ��' gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Ems'Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: ATr <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 1.2 gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspect r Reviewed Date: Entered Date: <br /> By Initial: 5.9 •l By Initial: — 3 <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more(of petroleu . <br /> **Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />