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SAN JOAI tUIN CO' LINTY <br /> I ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,`Stockton, CA 95202-3029: <br /> 4 Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> .ABOVEGROUND PETROLEUM STORAGE:PROGRAM SURVEY FORM <br /> <Facility Name: <br /> Page of <br /> Facility Address* t City: Inspecti Date: <br /> -77 <br /> Az/j <br /> FA#: PR#: Program Elemenk. <br /> D 3 UC/-- <br /> Tank/Container <br /> tsTank/Container friformation <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 /> [t Tank (2820) 1:1Containers (2821) *of Containers: TA#: <br /> 1 Total Capacity: C gallons Pro' Type: 4 <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Vank ) E3(2820Containers (2821) #of Containers: T #: <br /> .2 �. <br /> Total Capacity. 0_?) gallons Product Type: <br /> fper tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of.Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: .TA#: <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> i <br /> #of Containers: TA#: <br /> El Tank (2820) El Containers (2821) - <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> a <br /> Total Capacity this Page: L000 Loogallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> L;S-�L - 1By Initial: r�,�-� By Initial: 0. <br /> 24L24 <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 r <br /> 0911210a AST SURVEY FORM <br />