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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 /> G' lan Page of 2 <br /> Facility Address: City: Inspection D 7 <br /> to: <br /> FA#: PR#: Program Element: <br /> ��2 "- a <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 /> N Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 4A-Total Capacity: 2 2 gallons Product Type: a S E d O/ <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) 2/Containers (2821) #of Containers: TA#: `, l q _ <br /> 2Product TypeZ>1 -el� <br /> TOtal Capacity: / O O gallons <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ❑ Tank (2820) 2/containers (2821) #of Containers: TA#: <br /> ,Total Capacity: l 0 gallons Product Type: Hydie- <br /> rou- <br /> (per tank or cumulative for containers by product type) d <br /> Install Date: <br /> ❑ Tank (2820) Containers (2821) <br /> 0o(petr <br /> al Capacity: GJ� gallons Product Type: �dm(-az fin tank or cumulative for containers by product type) Install Date: <br /> 52/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 46-1 <br /> 6Total Capacity: JO Product Type: �M� / i � pI �'ogallons (ef <br /> a <br /> 0 (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 5 gallons Total Capacity for Site: t169&S gallons <br /> Comments: <br /> 141 tJ ,- +1 <br /> EHD In or: Reviewed J Date: Entered Date: 3 <br /> By Initial: f7,L`i.�Q By Initial: <br /> *Abov gro d storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> "Confaider means a storage device designed to be moved when full. <br /> EHD 28.01 <br /> 09/12/08 <br /> AST SURVEY FORM <br />