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SAN JOAQUIN COUNTY <br /> a <br /> µ ENVIRONMENTAL HEALTH DEPARTMENT <br /> t•- �� 600 East Maui 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: Page —/—Of <br /> o 12 Facility Ad s: City: Inspect Date_ Q <br /> IviZ. 0rI� <br /> FA#: PR#: Program'2 <br /> Tank/.Container Information <br /> Complete for all sites with,cumulative aboveground storage of petroleum ?1,320 gallons in tanks` and containers"*. <br /> Com fete one box for each tank or each cumulative container product ty2e. <br /> ©'Tank (2820) ❑ 'Containers (2821) <br /> #of Containers: TA# <br /> 1 Product Type: <br /> Total Capacity: �Ga gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> U,, ank (2820) ❑ Containers (2821) #of Containers: T,�#: <br /> 2 Total Capacity: J'O gallons Product Type: <br />` (per tank or cumulative for containers by product type) Install Date: <br /> l <br /> E� Tank (2820) ❑ #of Containers: TA#: <br /> 'Containers (2821) <br /> 3 - Product Type: <br /> Total Capacity: 2—/ D gallons. <br /> (per tank or cumulative for containers by product type) Install Date: <br /> r <br /> #of Containers: 1 TA#: x y <br /> Tank (2820) ❑'containers (2821) r / <br /> 4it allons Product Type: . s F� �ly <br /> Total Capacity: ' g <br /> (per tank or cumulative for containers by product type) Install Date.- <br /> El <br /> ate:❑ Tank (2820) ❑ Containers (2821) .#of 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: l o gallons TTOZI Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By initial: �{•`}l e� By Initial: <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 AST SURVEY FORM <br /> �\ 09/12/08 — _ � <br />