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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENO <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 __L of—L <br /> Facility Address: City: Inspe!M&-ate: <br /> l50 5W , � S�CI�c� ! 22 // <br /> FA#' PR#: Program Element: <br /> �0-70(o ez;� 8 3Z <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 /> Tank (2820) ❑ Containers (2821) *of Containers: TA#: 2.520 <br /> 1 Product Type: <br /> Total Capacity: O (Dgallons <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ank (2820) ❑ Containers (2821) �tofiCDntamers. —'rA#°-�tz���� <br /> 2 0 0 0 gallons Product Type: e <br /> Total Capacity: . � D, <br /> (per tank or cumulative for containers by product type) <br /> 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 /> ❑ 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: .9 Q 1 D 0 0 gallons Total Capacity for Site: DOD gallons <br /> Comments: <br /> EHD Insp r' Reviewed Date: ^!,� �, B;Ina al Dater a <br /> Re Initial: l"' / <br /> "Abovegr n rage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> "ContainbrTneans a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />