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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: Page of <br /> A � <br /> Facility Address: City: Inspection Date: <br /> r a a <br /> FA#: I PR M. Prog EEem nt. <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum al,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: <br /> Total Capacity: o gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> [I Tank (2820) ElContainers (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 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers byproduct type) Install Date: <br /> Total Capacity this Page: 3 gallons Total Capacity for Site: 13,30 gallons <br /> Comments: <br /> EHD Inspector: 1� Reviewed Date: Entered Date: <br /> By Initial: wvov . By Initial: <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 />