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SAN JOAQUIN COUNTY 0 <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 Na e: <br /> Facility Address: <br /> Page of <br /> r, I I / City: Inspection Date: <br /> FA#E: W l/ � 04. <br /> I, •,l <br /> PR Program Element: <br /> Z3 Z�3 <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 /> 7TR P2820 ED Containers (2821) #of Containers: TA#: <br /> 1 Total Capacity: gallons Product Type: VA'M f(� 7�Jr�,► <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> l� <br /> .r a (rm 2 2) 11 Containers (2821) #of Containers: TA#: aD� <br /> 2 gallon„ Product Type: ( l�A, � U� -l� � <br /> Total Capacity: � � qq.�/0,,_�,N1 �;LJ,�- n <br /> (per tank or cumulative for containers by product type) Y_�'Vild Vl+ •r/ 1. r�L r1 <br /> 1L��y,� <br /> Install Date: 111 r �D6 <br /> LA <br /> ank� . (2820) ❑ Containers (2821) *of Containers: TA#: �D, ) <br /> 3 Total Capacity: Product Type: aw III, -+ Pq D �� <br /> p y: gallons —�---- r <br /> (per tank or cumulative for containers by product type) <br /> Install Date: ]1/ "(ho, <br /> r(per <br /> nk (2� ❑ Containers (2821) #of Containers: TA#: <br /> 4 Product Type: �, <br /> Capacity: (� gallons <br /> k 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) <br /> Install Date: <br /> Total Capacity this Page: �'.` (� gallons Total Capacity for Site: <br /> b gallons <br /> Comments: <br /> EH D Inspector: Reviewed n�� Date <br /> �`/ Entered Date: <br /> - ( By Initial: `� 11 By initial: h lt� <br /> '`Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. 7oC- <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />