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;. SAN JOAQUIN COUNTY 4 �< s 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 Address: ty: Inspectio Dat 0 5-0 r 'L�N/ � S �. FA#: PR Program Elemen . Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2-1,320 gallons in tanks'and containers". Complete one box for each tank or each cumulative container product type. ank (2820) ED Containers (2821) #of Containers: TA#: _ L 1 Product Type: , n�p� Total Capacity: gallons (per tank or cumulative for cc6tainers by product type) Install Date: %—D.TIi ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (2821) #of Containers: TA#: a 3 Total Capacity: 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: u ElTank (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: EHD Inspector: Reviewed Date: Entered Date: J By Initial: 2-j,Lp,� By Initial: `Aboveground storage tank means a tank that has the capacity to store 55 gallons or more 6T petroleum. *"Container means a storage device designed to be moved when full. EHD 28-01 ;AST SURVEY FORM 09/12108