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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 /> 5 Page_ of <br /> Facility Address: ci Inspel n ate: <br /> FA#. Program Ele n� <br /> Tank/Container Information t <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks` and containers". <br /> Complete one box for each tank or each cumulative container product type <br /> [ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 ( Product Type: l <br /> Total Capacity: _ X� gallons <br /> (per tank or cumulative for containers by product type) <br /> Install Date: 1(/ <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) <br /> 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 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulabve for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: Product Type: <br /> P y: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: �-U L; gallons <br /> Comments: <br /> EHD Inspe Reviewed Date: Entered Dater av <br /> By Initial: �, -l0 By Initial: t' o D <br /> *Aboveg,rQ0h5Atoragtank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> "Cont means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />