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SAN JOAiUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(20:9)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Nam <br /> �� mss- Page of <br /> Facility ddress: City: Inspection ate: <br /> FA#: PR#: 1. Progra Element: <br /> o D �3 �- <br /> TanklContaihiu 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) #af Containers: TA#: <br /> 1 �-'Total Capacity: Product Type: 6:6Sgallons a. <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> .l: <br /> 2 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ElTank (2820) ❑ Containers (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 /> El Tank (2820) El Containers Containers: TA#:Containers (2821) ,i <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> a <br /> El Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: fj gallons j; Total Capacity for Site: gallons <br /> Comments: CI L� <br /> . v <br /> EHD Inspector: /7 Reviewed Date: Entered Date: <br /> By initial: 41.`�j•9� By Initial: <br /> VA j <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 I <br />