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SAN JOAQUEN COUNTY <br /> qNVIRONMENTAL <br /> 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: Page of <br /> Facility Address: City: Inspection ate- <br /> AAE <br /> FA#: PR#: Progra Eie ent: <br /> � Lv `? 73 /fa <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 t e. <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Total Capacity: Product Type: �7 ` <br /> p y: gallons <br /> (p'er tank or cumulative for containers by product type) Install Date: <br /> Lia Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Product Type: <br /> Total Capacity: 0 0 gallons - <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br />�r <br /> ❑ 'Tank (2820) Vcontainers (2821) #of Containers: �_ TA#: <br /> 3Product Type: A 5TC <br /> �j <br /> Total Capacity: © gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 11 Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> t <br /> ElTank (2820) ElContainers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: ( O 4 gallons Total Capacity for Site: / O K Q gallons <br /> Comments: C <br /> EHD Inspector: Reviewed Date: Entered Dat <br /> C_ By Initial: > i°I,d°1I <br /> By Initial: a2le <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 !FAST SURVEY FORM <br /> 09/12108 j <br />