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k. SAN JOAQUIN COUNTY, <br /> 4ENVIRONMENTAL HEALTH DEPARTMENT f <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROrUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> U 1 T` Page of <br /> Facility Address: City: Inspect on Q te: <br /> r <br /> FA#: P #: Prog m em t: <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 eroduct type, <br /> VTank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Total Capacity: g <br /> !O Q allons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Ca acit Product Type: <br /> p y: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ 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 /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5Total Capacity: " .i gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity gallons <br /> Comments: ------- <br /> r <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: O� 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 i w: AST SURVEY FORM <br /> 09/12/08 , .y <br />