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SAN JOAQUIN COUNTY i ENVIRONMENTAL HEALTH DEPARTMENT T 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209) 468-3420 Fax: (209)'468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Na e: Page 1—of FacilityA dress: City: Inspecti n D te. �p 11-24 9 1? FA#: PR M Program EE a t: 1767 5 z Tank/Container:Information Complete for all sites with cumulative aboveground storage.of petroleum 21,320 gallons in tanks'and containers". Com let one box for each tank or each cumulative container Rroduct type. ❑ Tank (2820) Containers (2821) #of Containers: _� TA#: 1 Product Type: 01 Total Capacity: gallons (per tank or cumulative for contairiepf by product type) Install Date: ` ElTank (2820) 13Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ElContainers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ElContainers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers'by product type) I nStall :Date: Total Capacity this Page: ( �gallonsTotal Capacity for Site: �'" gallons Comments: k EHD Inspector; Reviewed Date: Entered Date: By Initial: '�.(o-Q1 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 fuli. EHD 28-01 AST SURVEY FORM 09112108