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SAN JOAQUIN 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/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: _ <br /> Facility Address: ' Page __L of Z <br /> Z A /N h y: Inspection ate: <br /> FA#: PR#: ✓ ry 7��� /O <br /> Programement: <br /> Tank/Container Information LL O <br /> Complete for all sites with cu lative aboveground storage of petroleum 21,320 gallons in tanks'and containers". <br /> Com le one box for each tank or each cumulative container product type. <br /> ❑ Tank (2820) Containers (2821) #of Containers: 3 TA#: <br /> 1 Product Type: i"!v%_/L <br /> Total Capacity: f{� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <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) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ 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 /> 5 Total Capacity: gallons Product Type: <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: <br /> Entered Date: <br /> Reviewed Date: q <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 /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />