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{ <br /> 'A <br /> SAN.1OAQUIN 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: <br /> Tr l/�ti mp `P N7 A a S Page of <br /> Facility Address: r, a city: Inspect n Date: <br /> FA#: PR M Pr ra Elem-e ;O <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers". <br /> Com lete one box for each tank or each cumulative container producttype. <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#:-7 <br /> 1 5D Product Type:----—R 6 - --- <br /> Total Capacity: 3 gallons ' <br /> (per tank or cumulative for containers by product type) Install Date: <br /> i <br /> Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> I <br /> 2 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank 2820 Vcontainers 2821 #of Containers: TAO: <br /> 3Product Type: <br /> Total Capacity: gallons . <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (2820) D Containers (2821) <br /> #of Containers: TA#: <br /> 4 - Product Type: <br /> Total Capacity: gallons y <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type:' <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> Total Capacity this Page: Q gallons Total Capacity for Site: � `t gallons <br /> a , <br /> Comments: f <br /> z - 09 <br /> EHD Inspector: Reviewed Date: Entered Date: . <br /> By Initial: 01 oov 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 /> i EHD 28-01 .AST SURVEY FORM <br /> 09/12/08 li <br /> a <br />