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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: I/ , <br /> zvLCzZ./ Page –j— of <br /> Facility Address City: Ins7ct/n ata <br /> D P 14F• U <br /> FA M PR M Program Element: <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 /> ff—Tank (2820) ❑ Containers (2821) #of Containers: TA#: p <br /> 1 Product Type: –laS 4 <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> V,,fank (2820) Containers (2821) *of Containers: TAS <br /> 2 Product Type: .,P J <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) I nstall Date: <br /> El Tank (2820) ElContainers (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: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Data: <br /> By Initial: + � �re�{ By Initial: a� O <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 26-01 AST SURVEY FORM <br /> 09!12108 - <br />