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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 />T <br />Page of <br />GO T <br />� <br />Facility Address: <br />City: <br />Inspectio Date: <br />00 r <br />V <br />FA #: r <br />PR M <br />Program Element: <br />6 <br />u <br />Tank/Container Information <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) <br />#of Containers: TA#: PEI S 00 7 <br />1Product <br />Total Capacity: ��p d 8 gallons <br />Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />2 <br />Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />3 <br />Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />4 <br />Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />5 <br />Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: ` j p �-hs� <br />gallons <br />Total Capacity for Site: <br />_QQ jJ gallons <br />Comments: <br />EHD Inspector: <br />�. <br />Reviewed Date: I <br />By Initial: ` , .1 q, 5-(� <br />Entered Date: <br />By Initial: � ,-v <br />"Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br />"Container means a storage device designed to be moved when full. <br />EHD 28-01 AST SURVEY FORM <br />09/12/08 <br />