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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 /> ff#: <br /> 7nICO1_,,A0p -7-ne Page 2 of 2 City:� Ins�c on DPR M Program Element: <br /> 8 6 2 S' /3 8 280/ <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks'and containers", <br /> Com tete one box for each tank or each cumulative container product t e. <br /> ❑ Tank (2820) Containers (2821) #of Containers: Z TA#: _F <br /> 1 Product Type: <br /> Total Capacity: - �5 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2Product <br /> Total Capacity: gallons Type: <br /> (per tank orcumulative for containers by producttype) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for mntalners by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ❑ 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: r'C-3 gallons Total Capacity for Site: ! �P(��- / / gallons <br /> Comments: <br /> EHD In or: _ Reviewed Date: Entered <br /> Date: <br /> ,.. By Initial: (�il11`t �{ 1 � i( By Initial: <br /> Abo gr nd storage tank m�a7fs a lank that has the capacity to store 515 gallons or more of petroleum. <br /> ."Co Iner means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />