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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 Name: <br /> ` Page� of <br /> Facility Address: Cit Inspection Date: <br /> -70-3 <br /> FA#: PR#: O Pam I <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#: 4�2 � <br /> 1 Total Capacity: G allonsProduct Type: , <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 0.X Tank (2820) ❑ Containers (2821) #of Containers: TA#: D,g l ?got 3 <br /> 2 Product Type: <br /> Total Capacity: � gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> T/Tank (2820) ElContainers (2821) <br /> #of Containers: TA#: Dom ) <br /> 3 Product Type: <br /> Total Capacity: 0gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (2820) #of Containers: TA#:Containers (2821) o <br /> 4 Product Type: �/ e <br /> Total Capacity: ��b gallons <br /> (per tank or cumulative for containers by product type) Install Date.- <br /> El <br /> ate:❑ 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: QD gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD ctor: Reviewed Date: Entered Date: <br /> By Initial: By Initial: 0 <br /> oveg and storage tank mea s a tank that has the capacity to store 55 gallons or more of petroleum. <br /> '"Co finer means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />