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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.sigov.orglehd <br /> ABOVEGROUND PETROLEUM STORAGE=PROGRAM SURVEY FORM <br /> Facility Name: <br /> :Page 11 of <br /> Facility A dr ss: w City: . 33 Inspection <br /> FA M PR#: s Program Element: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum x1,320 gallons in tanks`and containers*. <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) ElContainers (2821) #o#Containers: J TA#: <br /> 1 Total Capacity: 01) gallons Product Type: <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 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) 0 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) 0 Containers (2821) #of Containers: TA#: <br /> s 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: J�p gallons <br /> Comments: <br /> EHD inspector: Reviewed Date: ,( Entered Date: <br /> 8y Initial: `b a1-0`b By Initial: t7 <br /> "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> "Containermeans a storage device designed to be moved when full. *� <br /> EHD 28-01 ! AST SURVEY FORM <br /> 09/12/08 <br />