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Yi <br /> 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 /> ABOVa?EGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: Page of <br /> D <br /> Facility Address: City: Inspection ate <br /> 2. 00'5 ! 5• i�v� � � <br /> FA#: PR#: Program Ele <br /> 8'6 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum X1,320 gallons in tanks*and containersk". <br /> Complete one box for each tank or each cumulative container product tXpe. <br /> ank (2820) C3 Containers (2821) #af Containers: TA#: <br /> J <br /> 1 ` gallons <br /> Product Type: <br /> Total Capacity: P� g <br /> (per tank or cumulative for containers by product type) Install Date: <br /> t.. <br /> ank (2820) ❑ Containers (2821) <br /> #of Containers: TA#: <br /> 2 1 . Product Type: <br /> Total Capacity: z"Tj gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank 2820 El Containers (282.1). #of Containers: TA#: <br /> t 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> I <br /> i <br /> ❑ Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> i' <br /> fi #of Containers: TA#: <br /> ❑ Tank (2820) ❑ Containers (2821) <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> €fi <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> t; By Initial: .01. 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 /> EHD 28-01 3 <br /> AST SURVEY FORM <br /> 09/12/08 li <br />