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00 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: P � <br /> L, 0 ( NG # v Page of <br /> Facility Address: City: Inspection q t� Of <br /> S/ - Oh/r� ,i F >5 <br /> FA#: PR#: Program Elemt: <br /> 2- 7-s <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) ❑ Containers (2821) #of Containers: TA#: <br /> e /sit A- <br /> 1 Total Capacity: O D gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 2-- ank (2820) ❑ Containers (2821) #of Containers: TA#: 3 <br /> 2 Product Type: "V S <br /> Total Capacity: �'o d gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> #of Containers: TA-9.L'YTank (2820) El Containers (2821) <br /> 3 Total Capacity: J0� oy Product Type: <br /> gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> [I Tank (2820) L� on <br /> Ctainers (2821) #of Container - TA#: <br /> 4Product Type: n %0'ly <br /> Total Capacity: �J 1` C� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ontainers (2821) #of Containers: TA#: <br /> 5 Total Capacity: //Z7 gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: d gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> - vv By Initial: By Initial: 6 <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 />