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_ 4- SAN.IOA(2UIN COUNTY <br /> yt <br /> {` o •_' ENVIRONMENTAL HEALTH DEPARTMENT � x <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:w+nrw.sjgov.orglehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Na e: Page L Of <br /> a <br /> Facility Address: �. Gty; Inspecti/Da7,2Z0 ! 5 . L . ! L 10� �r.Q .� <br /> FA M. PR M. Progrr7 2- 07 TIPo 5�-!t> 0 1 K t> am Ef nqto <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum =-1,320 gallons in tanks*and containers". <br /> Complete one box for each tank or each cumulative container product type. <br /> Q Tank (2820) El Containers Containers: TA#:Containers (2821) a <br /> 1Product Type:'_ <br /> Total Capacity: 5 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (2820) ElContainers (2821) #of Containers: TA#: <br /> 2 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 11 Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (2820) ElContainers (2821) #af Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> d <br /> ElTank (2820) ❑ Containers (2821) .#of Containers: TA#: <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallonsTotal Capacity for Site: gallons <br /> Comments: <br /> 4 <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: VA By Initial: +� Q <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 />