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Y _l <br /> SAN.IOAQUIN COUNTY <br /> t ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> i Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjg0v.org/ehd <br /> ABOVEGROUND PETROLEUM'STORAGE"PROGRAM SURVEY <br /> Facility Name: FORM <br /> { <br /> Facility Andress: Page of <br /> City: Inspection D�tD <br /> te: <br /> FAM Pi=#: D4 �4 2 D< Proprani Eleent: <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 /> 1 <br /> Total Capacity: ��� gallons Product Type; <br /> (Per tank or cumulative for containers byproduct type) <br /> �1Go�_ aft <br /> Install Date: ' ` <br /> ank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 °Product Type: <br /> Total Capacity: Z gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) ; #of Containers: TA#. <br /> 3Product Type: ' �� � �� <br /> Total Capacity: 0 gallons � -I � �— � <br /> (per tank or cumulative for containers by product type) cor�o 1(cfa v <br /> Install Date: 1 <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Product Type: <br /> Total Capacity: gallons _ <br /> (per tank or cumulative for containers byproduct type) Install Date. <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM <br /> 5 Total Capacity: allons Product Type: <br /> (per tank or cumulative for containers by product type) <br /> Install ©ate; <br /> Total Capacity this page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> i <br /> Ei 1D Inspector: Reviewed[ Date: Entered Date: <br /> By Initial 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 /> CH 28-D1 <br /> 09112/08 AST SURVEY FORM <br />