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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 /> CO%cif Page -1-L- of <br /> Facility Address: City: Insp ction Date: <br /> 03 <br /> e;7//L <br /> FA#: PR M Program Element: <br /> aF32 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers". <br /> �� <br /> Complete one box for each tank or each cumulative container product type. <br /> L7 Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Product Type: 61, fO t <br /> Total Capacity: 4, 00 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> N,/Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2Product Type: lid Q /vr 0 <br /> Total Capacity: —_�� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: 15Sl <br /> 3 Product Type: ��/ /fes/ <br /> Total Capacity: �45V gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> E5/Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Product Type: `G <br /> Total Capacity: c9,00 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4A2 <br /> 5 Product Type: <br /> Total Capacity: rz gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD I ctor: Reviewed Date: Entered Date: <br /> By Initial: By Initial: D <br /> *A egr nd storage tank means a tank that has the capacity to store 55 gallons or more of pe roleum.7-7 <br /> "Co her means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />