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SAN JOAQUIN COUNTY Ir p� <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 e: (P <br /> iJ Cl <br /> Page t of y <br /> Facility Addres : City: Inspection D <br /> FA#: PR#: Program Elemen <br /> / 7-)—yo P�a �� 2X j 67 <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 /> Q)/tank (2820) ❑ Containers (2821) #of Containers: `` TA#: <br /> 1 Total Capacity: j P� �q gallons Product Type: (� <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Product Type: o G` <br /> Total Capacity: r c� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> #of Containers: TA#: 1-9 ©6cP <br /> El Tank (2820) containers (2821) _ <br /> 3 r Product Type: �J <br /> Total Capacity: j gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> [I Tank (2820) aContainers (2821) #of Containers: TA#: <br /> 4Product Type: <br /> Total Capacity: >^S` gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ElContainers (2821) #of Containers: TA#: ti 1 g D� <br /> 5Product Type: %"P r i v f <br /> Total Capacity: "7- � gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: �'LQ galla; s Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: vl� By Initial: <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or mor4opeqIr6lieum. <br /> **Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />