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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 /> r � Page of <br /> FacilityAddres : fiftyi Inspection Date: <br /> S 9 " �G�'T" �✓ b.4V�1 L. - 2 --- L� <br /> FA#: PR M Program Ele <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 /> Dank (2820) El Containers (2821) #of Containers:' T <br /> 1 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) © Containers (2821) `pf Containers: TA#: <br /> 25 gallons <br /> Product Type: i t l..r� S 1� <br /> Total Capacity: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> f] Tank (2820) ❑ Containers (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) ❑ Containers (2821) #of Containers: TA#: <br /> 4 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: `j gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By 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 /> EHp 28.01 # AST SURVEY FORM <br /> 09/12108 <br />