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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 /> Fa�Address: <br /> 4 _ <br /> Page of <br /> a il Cit <br /> Y: � Inspection Date: <br /> FA 9: <br /> G , I PR M Program Element: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks*and containers". <br /> Complete one box for each tank or each cumulative container product fype. <br /> ' Tank (2820) ❑ Containers (2821) #of Containers: TA#: /a <br /> 1 Total Capacity: vL gallons Product Type: W(- iNe 0"I <br /> (per tank or cumulative for containers by product type) Install Date: 'JI-IV- 0^^ <br /> t Tank (2820) ❑ Containers (2821) #of Containers: TA#: BS�pII <br /> 2Product Type: ��kWeV7 ` Ci <br /> Total Capacity: �� gallons <br /> (per tank or cumulative for containers by product type) Install Date: V*J ILS- <br /> $�P Tank (2820) El Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: �,Y:v gallons Product Type: ' <br /> (per tank or cumulative for containers by product type) Install Date: (]ht tT--^ <br /> ❑ Tank (2820) containers (2821) #of Containers: _ TA#: <br /> 4 6 Product Type: c;i 1 <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Product Type: <br /> Total Capacity: gallons <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: SA( ff�� 1 41 <br /> �^ <br /> (�ati"i' lN' V 1 ' , <br /> _7_ <br /> EHD Inspector: /1 Reviewed Date: I Entered Date: <br /> By Initial: 2 I 11 By Initial: l� <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 <br /> 09/12/08 AST SURVEY FORM <br />