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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.sigov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> Oo^jQ� Page I of <br /> Facility Address: <br /> 32 s N City: Inspection Date: <br /> FA#: PR#: Program Element: <br /> FAe--,C) IV zye -Z Ip 20 <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 roduct t e. <br /> T(p, <br /> ank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> Capacity: S V o gallonsProduct Type: gilo 1;v, <br /> ank or cumulative for containers by product type) Install Date: ti <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: Z r5) o gallons Product Type: us o f <br /> (per tank or cumulative for wntamers by product type) Install Date: ,,, IGr+pw,„_ <br /> ❑ Tank (2820) -STContainers (2821) #of Containers. TA#: <br /> 3 Product Type: <br /> Total Capacity: _ gallons - <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Product Type: <br /> Total Capacity: gallons <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) <br /> Install Date: <br /> Total Capacity this Page: -7po gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Ins dor Reviewed Date: Entered Date: <br /> By Initial: By Initial: L/ <br /> t�nb e round storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> ontainer means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />