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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 Nam,q: <br /> pom 2ON�t� Page of <br /> Facility Address: y� city: �t Inspection ate <br /> c) 0 <br /> FA#: PR#: Program Ele ent: <br /> �. q r <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 /> C3'Tank (2820) El Containers (2821) #of Containers: TA#: h�" ~] 3 <br /> 1 L' r�► Product Type: � ! <br /> Total Capacity: d�' gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 2 Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 / Product Type: <br /> Total Capacity: / gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) El Containers (2821) #of Containers: '�A#: /� ) !' L-7S <br /> l <br /> 3Total Capacity: /,t"� Product Type: <br /> p y: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 0' Tank (2820) L1Containers (2821) #of Containers: / TA#: <br /> 4Product Type: ` A � <br /> Total Capacity: ,l d—t'Ae) gallons —z `-T° <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) C-Containers (2821) #of Containers: �_ TA#: CzZh�"? <br /> 5 Total Capacity: r ! gallons Product Type: <br /> (per tank or cumulative for containSrs by product type) Install Date: <br /> Total Capacity this Page <br /> ag �� gallons Total Capacity for Site: �l gallons <br /> Comments: �` r .�� Jl.� <br /> EHD Inspector: /. Reviewed1 Date: Entered Date: <br /> By Initial: vlv ( By Initial: r'J <br /> *Aboveground storage 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 /> 09/12/08 <br />