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. � A <br /> 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: <br /> E f � L e f M cSRai� c976 hI - Page .�� . of <br /> Facilitv.AddrewCity: Inspecti n DP <br /> T-7- r b � illy <br /> FA -PR#: Program Ee t: <br /> 15 5,9 - Te <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 tyee. <br /> CO/Tank (2820) ❑ Containers {2821} <br /> #of Containers: _ TA#: <br /> 12.4 gallons Product Type: <br /> - -- ----- --- -- <br /> Total Capacity: � yp <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) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3. Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 171 Tank (2820) ElContainers (2821) #af 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: </ Al,f <br /> q 01°1 WC_171- <br /> l.fJ <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> C' By Initial: By Initial: �zj <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 /> EHE 28.01 AST SURVEY FORME <br /> 09/12/08 <br />