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SAN.IOAQUIN COUNTY (wtENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sjgov.org/ehd !il ABOVEGROUND PETROLEUM ST�ORAGERROGRAM SURVEY FORM Facility Name: p ? Page of Facility Address: City: Inspecti n Da FA#: PR#: Progra EI ment Z� Tank/Container Information Com ete for all sites with cumulative aboveground storage of petroieum 21,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of'!Containers: TA#: 1 � Pro.duct Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ElTank (2820) r. %ontainers (2821) #af iCantainers: TA#: 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: i El Tank (2820) El Containers (2821) #ofContainers: TA#: 3 Product Type: Total Capacity: gallons �. (per tank or cumulative for containers by product type) Install Date: !I: 11Tank (2820) El Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: I� El Tank (2820) ElContainers (2821) #of Containers: TA#: il { 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Ins tal I Date: Total Capacity this Page: 'j �� gallons. Total Capacity for Site: J� gallons r Comments: Z o EHD Inspector: Reviewed Date: Entered Date: By Initial: �,�. By initial: Q *Aboveground storage tank means a tank that has the dapacity to store 55 gallons or more of petroleum. **Container means a storage device designed to be moved when frill. EHD 28-01 `,I AST SURVEY FORM 09/12/08