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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$: <br /> #/ ,6A/ Page of <br /> Facility Addr sCity: Inspect! D te: <br /> l ? �'sf s, mll otG7 <br /> a <br /> FA#: PR#: Prograrh Element: <br /> c�S <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#: <br /> 1 Total Capacity: �, �( gallons Product Type: - j <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: 9b 12 71 b <br /> Total Capacity: 10 <br /> 2 0gallons Product Type: a- fp <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) 1:1 Containers (2821) #of Containers: TA#: 66-18 `7 f <br /> 3 Product Type: <br /> Total Capacity: / (1�6yo gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: / TA#: 6r( T-717- <br /> 4Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for conta ers by product type) Install Date: <br /> L <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: Z is.(rf gallons Total Capacity for Site: 2j-� gallons <br /> Comments: <br /> 1 <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: jJ ��`� By Initial: <br /> "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more cif petroleum <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09/1 2/08 <br />