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SAN JOAQUIN:COUNTY - ENVIRONMENTAL HEALTH DEPARTMENT ' yy600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 4' 68-3433 Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE!PROGRAM SURVEY FORM Facility Name: Page of Facility Addre s: p City: Inspect o Dote- A S- FA#: PR#: Programlement: Tank/Container Information Complete for all sites with cumulative aboveground storage"of petroleum 21,320 gallons in tanks`and containers". Complete one box for each tank or each cumulative container product type. ank (2820) 0 Containers (2821) #of Containers: TA#: 1 Product Type: Total Capacity: gallons gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: _ (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: t ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: } 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) I nstal I bate: M ElTank (2820) ❑ Containers (2821) #of Containers: TA#: k 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) I nstall'.Date: Total Capacity this Page: gallons ',Total Capacity for Site: gallons Comments: { EHD Inspector: Reviewed Date: Entered Date: By Initial: 6,10. By Initial: "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY fORM 09/12/08