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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: r <br /> Dlce 1, � lAl 1 G Page of <br /> Facility Address: , City: Inspect' n Dae; <br /> FA#: PRMI Progr#m Element: <br /> :3&) <B� :2- D <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 type, <br /> Tank (2820) 1:1 Containers (2821) #of Containers: TA#: <br /> 1 Product Type: <br /> Total Capacity: N - gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 'r #of Containers: TA#: <br /> El Tank (2820) [J"Containers (2821) f <br /> 2 Product Type: _�'j D,�,�� C�! <br /> Total Capacity: Z-'j gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑'Containers (2821) #of Containers: TA#: <br /> 3Product Type: <br /> Total Capacity: , -0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) El Containers (2821) #of Containers: TA#: ��SI q �� <br /> 4iProduct Type: <br /> Total Capacity: 0�' gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: f,*f 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: Lt/� gallons <br /> Comments: 2 ' <br /> r- 1 <br /> z y <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> CBy InitialBy Initial: <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more o 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 />