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SAN.fOAQUIIV COUNTY <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/ohd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM. <br /> Facility Name: <br /> Z--C> D page- / of <br /> Facility Address: city: Inspectlo Dat . <br /> FA#: PR#: Progral meri <br /> Tank/Container Information . <br /> Complete for all sites with cumulative aboveground storage of petroleum ;tl,320'gallons in tanks*and containers**. <br /> Complete one box for each tank or each cumulative container product type._ <br /> E� Tank (2820) ❑ Containers (2821) #ofi Containers: TA#�: <br /> 1 -Total Capacity: v OfiJ� gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: r <br /> U//Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: 10--Ot> gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br />` 11Tank (2820) ' ElContainers (2821) #of Containers: TA#: <br /> 4 Product Type: <br /> I Total Capacity: gallons <br /> i (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (2820) ❑ Containers (2821) <br /> #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> F <br /> Total Capacity this Page: �_ gallonsTotal Capacity for Site: gallons <br /> l Comments: <br /> EHD Inspector; .7 Reviewed Date: TBy <br /> ntered Date: <br /> By Initial: tj•�' Initial: <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more ol petroleum. <br /> **Container means a storage device designed to be moved when full. <br /> j EHE 28-01 AST SURVEY FORM <br /> . o9ti��na <br />