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�+ l <br /> SAN JOAQU4N 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: 1 of <br /> r !' Q (�/ -S N Page <br /> Facility Ad ess: City: Inspection te: <br /> 5 - ve;A sly, <br /> Program E le_ eltt: <br /> C� TanklContainer Information <br /> Complet or 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 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820)- ❑ Containers (2821) <br /> #of Containers: TA#: <br /> 2 Total Capacity: gallons Product Type: <br /> (pertank orcumulative for containers by product type) Install Date: <br /> b <br /> 1:1 Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Cdntainers (2821) #of Containers: TA#: <br /> Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) 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: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: tj-,I.Qci 8y Initial: <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 ,i AST SURVEY FORM <br /> 09/12108 <br />