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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 f of <br /> Facility Address: City: Inspection D te: <br /> 01D (?W Z G <br /> FA#: PR#: Pr g am Element: <br /> / 637/ 053035 2930 <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 /> ank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Total Capacity: / 0p ,gallons Product Type: <br /> (per tank or cumulative ror 66ntainers by oroduct type) Install Date: <br /> ank (2820) ❑ Containers (2821) #of Containers: TA#: P c !R Y <br /> 2 Product Type: 17�U <br /> Total Capacity: > � � gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> a'Tank (2820) 11 Containers (2821) #of Containers: <br /> f� TA#: <br /> Total Capacity: OeZ gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: p <br /> #of Contaiiar s: TA#: <br /> Tank (2820) El Containers (2821) t� <br /> 4 Product Type: L J✓L.�-@ <br /> Total Capacity: � n�J gallons <br /> ,61 <br /> (per tank or cumulative for containers by product type) Install Date: 77 <br /> El Tank (2820) CrIcontainers (2821) #of Containers: 2/ TA#: g <br /> 5Total Capacity: y , gallons Product Type: �iv/1 .� I G< <br /> (per tank or cumulative for contellnersby product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> Ad k <br /> EHD Inspector: �� Reviewed Date: Entered Date: <br /> By Initial: By Initial: 9 F71/11 ✓ <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum.( <br /> **Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br />