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SAN JOAQUIN COUNTY, x ENVIRONMENTAL HEALTH DEPARTMENT 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 Name: Page of Facility Address: ! city: Inspection Date- - so FA#: PR M Program Element: 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: :Total Capacity 10 gallons _ (per tank or cumulative for containers by product type) Install Date: 11 Tank (2820) R2 Containers (2821) #of Containers: TA#: 2 Product Type: ] ( •/ � Total Capacity: ��gallons (per tank or cumulative for contai rs by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Ca aci# Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: ►. 4 Product Type: Total Capacity: � gallons (per tank or cumulative for containers by product type) Install Date: F-1Tank (2820) ElContainers (2821) #of Containers: TA#: . 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 75 gallons Total Capacity for Site: 3 e) T gallons Comments: EHD Inspector: Reviewed i Date: Entered Dat f By Initial: '}•tipsn I By Initial: I �q *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. l v "Container means a storage device designed to be moved' full. EHD 28-01 AST SURVEY FORM 09/12/08 i