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3 <br /> ,_. ALIL SAN JOAQUIN COUNTY - <br /> mm4 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> la! C G 9 Page � of <br /> A <br /> Facility Address: City: Inspectl Date: <br /> FA M PR#: Program Element: <br /> o D a �. <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 2:1,320 gallons in tanks`and containers". <br /> Complete one box for each tank or each cumulative container product type. <br /> ank (2820) ❑ Containers (2821) #of Containers. TA#: <br /> 1 22 d <br /> Total Capacity: - /D O �9 gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821} #of Containers: TA#: <br /> 2 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ElTank (2820) 11Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (2820) ElContainers (2821) #of Containers: TA#: <br /> Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 5 <br /> El Tank (2820) ElContainers (2821) <br /> #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 4 Total Capacity this Page: 6 C� d gallons Total Capacity for Site: O el gallons <br /> Comments: <br /> I <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: _R04� By Initial: <br /> i r <br /> `Aboveground storage tank means a tank that has the capacity to store 55 gallons or more bf petroleum. <br /> *"Container means a storage device designed to be moved when full. <br /> EHD 28.01 AST SURVEY FORM <br /> 09/12/08 <br />