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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: ' Page of Facility A dress:Ci/rty: // Inspecti /D/ate �l / _ FA #: PR #: Program EI/eme • Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. El Tank(2820) 2/containers (2821) #of Containers: TA#: 1Product Total Capacity: S gallons Type: y %%�� /�% L/ O y (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 191 ontainers (2821) #of Containers: 2� TA#: 2 Total Capacity: O gallons p y: // Product Type: Z/1A_ `'% O/ (per tank or cumulative for containers by product type) Install Date: [;?�ank (2820) ElContainers (2821) #of Containers: TA#: 3 Total Capacity: 6 o d gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (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: r gallons Comments: EHD Inspector: y Reviewed Date: By Initial: Entered By Initial: Date: l� % *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 28-01 AST SURVEY FORM 09/12/08