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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: y� <br /> A • �A� L F O� Page l of � <br /> Facility Address: City: Inspect 01 pate: <br /> z 9) USN, r �s� Si9/o <br /> FA#: I rR M Prograin Element: <br /> �)0 2- <br /> Tank/Container <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 e. <br /> EI/Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Total Capacity: gallons Product Type: <br /> (per tank or cumulative f con ainers by product type) Install Date: <br /> E3 Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 2 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 /> 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 /> S 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: T_00 gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Da <br /> By Initial: VA By Initial:Z2 <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petrol um. <br /> *"Container means a storage device designed to be moved when full. <br /> EHD 28-01 AS- <br /> 09l12108 <br />