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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Y Telephone: (209) 468-3420 Fax: (209)46873433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page Of Mo or Iia Facility Address: City: Inspe tIIT O FA#: PR#: Program Element r� � 59 00 2 Tank/Container information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container product tyRe. WTank (2820) ElContainers (2821) #af Containers: TA#: 1 Total Capacity: aD gallons Product Type: _� 2 (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 b a alIons Product Type: Total Capacity: � g (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2824) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: [] .Tank (2820) ElContainers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons 'total Capacity for Site: � gallons Comments: �l q Ili 5 { EHD Inspector: Reviewed Date: Entered Date: By Initial: ,a fl C`� By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. **Container means a storage device designed to be moved when full. ' EHD 28-71 AST SURVEY FORM 09112108