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l <br /> X SAN JOAQUIN COUNTY <br /> tNVIRONMENTAL 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 /> L}iLJy1l G/►i� /��L�`I-� Page of 4— <br /> Facility Address: City: Inspecti te: <br /> 1 �' 2/ L • �//3!_ <br /> FA#: � f�� PR#: ProgramEde <br /> CDU( <br /> Tank/Container Information <br /> Complete for ail sites with cumulative aboveground storage of petroleum X11,320 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 Total Capacity: �7 gallons Product Type: �� D <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 'Tank (2820) ❑ Containers (2821) .#of Containers: T <br /> 2 Total Capacity: r� gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ 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 /> 11 Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 4 Total Capacity: Product Type: <br /> p y: gall°ns <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 /> f (per tank or cumulative for containers by product type) Install Date: <br /> r <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> 'ILK Lf t-&O <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: 10 By Initial: IZ if <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 /> 09/12/08 1 <br />