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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN`� <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 /> Facility Address:: Page �of <br /> 1 <br /> 6 �� �v City: In pe <br /> FAM /� PR 0: / V <br /> T 7 Program Ment: <br /> Tank/Container Information 3D <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. 3_ <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Total Capacity: r) gallons Product Type: ( Cl i9l <br /> (per tank a cumulative for containers by product type) <br /> Install Date: I <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ❑ Tank (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 /> 11 Tank (2820) El Containers (2821) #of Containers=TA#: <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> Total Capacity: gallons Product Type: <br /> 5 : <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: I Reviewed Date: Entered Date: <br /> By Initial: By Initial: B <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 /> 09/12/08 AST SURVEY FORM <br />