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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT J <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sjgov. y/eh <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM ��Cf <br /> Facility Name: <br /> Page of <br /> LDC _ <br /> Facility Address: City- Inspecti n Date: <br /> GG�1Cs� �� I z zo L o <br /> FA#: PR#: Program Element: <br /> Tank/Contairier 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 /> nk (2820) [►,'Containers (2821) #of Containers: Tl( : <br /> Total CapaC. `T gallons <br /> Product Type- c l 0 /-I <br /> (per tank or cumulativeFS, ntainers by product type) <br /> Install Date <br /> El Tank (2820) Contain res(,2,821) # ontainers: TA#: <br /> Total Capacity: Z Z gal s Product Type: Vl Q e <br /> (per tank or cumulative for containers by product ype) Ia Date: <br /> ❑ Tank (2820) ontainers (2821) #of Containers: TA#: <br /> Product Type: Oil/ <br /> Total Opacity: � � gallons A <br /> (per or cumulative for containers by product type) Install Date: <br /> 'y Tank (2820) El Containers (2821) #of Containers: T TA#: ��'1 LP D <br /> 4 Product Type: <br /> Total Capacity: ) gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ontainers (2821) #of Containers: _ 2- _ T//A#: } �/ <br /> 5 I is Product Type: 0 f <br /> ,------.)Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: Irons <br /> Comments: <br /> `O Ci q1 i <br /> l / e <br /> 1 <br /> " ''1(�Z - ks rill/(- r <br /> -�KLv <br /> EHD Inspector Reviewed Date: Entered Date: <br /> By Initial: By Initial: <br /> "Aboveground storage tank mea a tank that has the capacity to store 55 gallons or more of petroleum. 7 <br /> "Container means a storage ci vice designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> osis was <br />