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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 ��Page � of <br /> Facility Address: <br /> ��I ,L I / i i r City: Inspects te: <br /> FA#: PIR <br /> I C) ✓ � I,I� �> �,.1 ,��� Program mer)t: <br /> Tank/Container Information <br /> C e or 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) ,❑'Co tners (2821) #of Containers: - TA#: <br /> 1 CI �'ZI - <br /> Total Capacity: _� �,, gallons Product Type: 4c) <br /> (per tank or cumulative for containers by Install Date: +-&7F 7 fT J <br /> 1 —I 1'l'J <br /> Tank (2820) ,�'Contalners (2821) #of Containers: � TA#: <br /> El <br /> 2 Total Capacity: -1��� gallons Product Type: r"v An ' �, <br /> (per tank or cumulative for containers by product type) Install Date: e a h-lm- <br /> ❑ Tank (2820) 11Containers (2821) #of Containers: TA#: <br /> 3 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product 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) <br /> Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: Product Type: <br /> p Y� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: .�— gallons Total Capacity for Site a gallons <br /> Comments: <br /> EHD Inspector: 11 Reviewed Date: Entered Date: <br /> art I By Initial: YL, kn,1 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 <br /> 09/12/08 AST SURVEY FORM <br />