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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN-I <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 /> J SS-rf. Sid � D, Page of <br /> Facility Address: City: I s ectio Date: <br /> o S - -_ . c(�{z � 2�� <br /> FA#: PR M Program lement: <br /> ` 3 -7 1 U -> �(4�' `// �- ��2 5 ::�21 <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#: ,1220 <br /> 1 Product Type: / JOL i— 0/ I <br /> Total Capacity: ,;?',C5 15 `� gallons 1 <br /> (per tank or cumulative for containers by product type) Install Date: (�c �aQ) <br /> 13 Tank (2820) Containers (2821) #of Containers: TA#: <br /> 2 Product Type: 0 __310 9 aX <br /> Total Capacity: gallons —T <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <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: gallons Total Capacity for Site: L/c- gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date.- <br /> By <br /> ate:By Initial: `�� �� Lb � By Initial: <br /> *Aboveground orage 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 /> 09/12/06 <br />