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DSAW.{QAQUIN COUNTY ot, <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 /> qv�a fL l�5 TI jG I �n/� Page of f <br /> Facility Address: ° ctty: Inspection Dat : <br /> FA#: PR#: Program Element: <br /> 0 0 2 3a <br /> Tank/Container information <br /> Complete for all sites with cumulative aboveground storage of petroleum X1,320 gallons in tanks*and containers*". <br /> Complete one box for each tank or each cumulative container product type. <br /> i Tank (2820) ❑ Containers (2821) > #of Containers: ,TA#: <br /> 1 <br /> Total Capacity: AO(ZO...;_t gallons Product Type: <br /> (per tank or cumulative for containers by product type) install Date: <br /> ji #of Containers: TA#: <br /> Tank (2820) ❑ Containers (2821)-L�--� •••_ <br /> 2 Total Capacity: t>- gallons Product Type: <br /> {per tank or cumulative for containers by product type} Install Date: <br /> :rte ,ank (2820) �ntainers (2821) #of Containers: �� TA#: <br /> 3 - --, �T Product Type: i4 �1 G 01 U <br /> Total Capacity: _� _c gallons <br /> (per tank or cumulative for containers Dy product type) Install Date: <br /> f rte, #of Containers: TA#: &, 72 <br /> q ank (2820) 9/containers (2821) <br /> 4 Product Type: �� N O L <br /> Total Capacity: Z gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) MOContainers (2821) #of Containers: _ TA#: <br /> 5 11 CJ-� Product Type: U <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> total Capacity this Page: a gallo' tel Capacity for.Site: gallons <br /> Comments: TONS' <br /> i <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> o ' Ray Initial: -1.@� By Initial: /9 911 <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 <br /> 108 <br /> 08!12/08 AST SURVEY FORM <br /> '• <br />