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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 />roki1� ^'J s Page of <br />Facility Address: l !1 r City; Inspection ate: <br />FA ;'/: O ,� PR M Progr fn 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 #of,Con)tainers: T <br />1 <br />Total Capacity:41X� <br />,gallon(per tank or cumulative by product type) Install Date: <br />�' Tank (2820) ❑ Containers (2>��-odtueffyp&----d�w <br />ontainers: (TTA,`#: <br />2 Total Capacity:—q.gallo I <br />(per tank or cumulative for co tainers by oroduet Install Date: <br />ElTank (2820) 2 Containers (28201 #of Containers: i : L dr - <br />5 Total Capacity: ns roduct Type: ( r6ui�r <br />(per tank or cumuI finers byproduct type) Install Date: <br />Total Capacity this Page: gallons Total Capacity for Site: gallons <br />Comments: 14; i � 1 I <br />' 1 k) <br />— <br />EHD Inspector: Reviewed Date: Entered Date <br />By Initial: Q�t� t.t (� 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 <br />AST SURVEY FORM <br />Tank (2820) <br />❑nC\ontainM (2 2 <br />#of Con hers. <br />3 <br />Total Capacity: <br />9'V \ I ons <br />Product Type: <br />Pr <br />(per tank or cumulative for contain product type) <br />Install Date: <br />❑ Tank (2820) <br />WContainers (2821 <br />*of Containers: <br />4 <br />Total Capacity: <br />uct Type: <br />tj� 0 i l— <br />(per tank or cumulative for vainer roduct type) <br />Install Date: <br />ElTank (2820) 2 Containers (28201 #of Containers: i : L dr - <br />5 Total Capacity: ns roduct Type: ( r6ui�r <br />(per tank or cumuI finers byproduct type) Install Date: <br />Total Capacity this Page: gallons Total Capacity for Site: gallons <br />Comments: 14; i � 1 I <br />' 1 k) <br />— <br />EHD Inspector: Reviewed Date: Entered Date <br />By Initial: Q�t� t.t (� 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 <br />AST SURVEY FORM <br />