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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: <br /> Page / of <br /> Facility Address: City: Inspection Date: <br /> FA#: PR#: program Elemen <br /> � 3b1 y9 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 2:1,320 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 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 /> 2 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers byproduct 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) ❑ Container s`(2821} #of Containers: TA#: <br /> 4 Total Ca acit Product Type: <br /> p y: gallons <br /> a (pertank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: 3S-0 gallons <br /> Comments: <br /> EHD Inspectorr Reviewed Date: Entered Date: <br /> 13y initial: 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 /> 09112/08 <br />