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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 />storage <br />act t y arae. <br />` q <br />Page of <br />Facility Address: <br />l I D <br />City:I ,� � <br />J1`Jti� i Lh,k S � <br />Inspectlon pate. <br />-)I -1 <br />) <br />FA #: PR #: <br />�F�irogF EI nt: <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) <br />*of Containers: T,^A,``#: <br />1 <br />! j { <br />Total Capacity: { i�� gallons <br />Product Type: V <br />(per tank or cumulative for Containers by product type) <br />Install Date: <br />2Product <br />Tank (2820) ElContainers (2821) <br />#of Containers: TA#: <br />dl <br />Total Capacity: (,�'� gallons <br />Type: C6"Y' <br />(per tank or cumulative for co tainers by product type) <br />Install Date: <br />$dank (2820) (2821) <br />#of Containers: TA <br />TAMContainers <br />3 <br />�❑ <br />Total Capacity: � <br />p Y gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: �vU( <br />❑ Tank (2820) ETContainers (2821) <br />#of Containers: TA#: c9 Sg' <br />4i <br />Total Capacity: �� gallons <br />Product Type: t� � 1 k_ <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) d Containers (2821) <br />#of Containers: TA#: <br />5 <br />Total Capacity: `- <br />p y: gallons <br />Product Type: VBuh� ,�1. <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: `� ��� <br />gallons <br />Total Capacity for Site: ��� gallons <br />Comments: ��1\ d,,��� V(nXVt'X • <br />(�jl� �} <br />EHD Inspector. , <br />.�e ..____. _� <br />Reviewed Date: <br />Initial: "�:r <br />! <br />(1 <br />Entered 77'q <br />By Initial: <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 <br />09/12/08 AST SURVEY FORM <br />