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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 Of <br /> Facility Address: city: Ins c on D te: <br /> o.?/a zn � fir, � rI � <br /> FA#: PR#: Program Element: <br /> o33 aL?� <br /> TanPJContainer 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 /> ,k Tank (2820) ❑ Containers (2821) #of Containers: TA#: Sly ��� <br /> 1 Product Type: �S(� <br /> Total Capacity: 00� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) El Containers (2821) #of Containers: TA#: '�' <br /> 2 / Product Type: <br /> Total Capacity: r �(� (:� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> LYTank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Total Capacity: /c�fl gallons Product Type: ,/" _ I Gi <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) "of Containers: aTA#: h�c2/`�/�/hy �• �/ <br /> 5 ' Product Type:Total Capacity: � ] gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 5 gallons Total Capacity for Site: c4�5 gallons <br /> Comments: <br /> EHD Inspector: ReviewedDate: Entered Date: <br /> By Inftial: v1,/�'" 3 I'D 1 I By Initial: <br /> *Abovo,qWund 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 <br /> 09/12/08 <br /> AST SURVEY FORM <br />