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_ SAN JOAQUIN COUNTY � N ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420'Fax:(209)468-3433 Web:www.sjgov,orglehd i ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: / Page j of i Facility Address: � �� City: Inspectjbn��te:� D r-- /C C 7 8 FA#: PR M Program Element: 0 FO 17 05R $`'off -- $ `�O Tank/Container Information Complete f .all sites with cumulative aboveground storage of petroleum X1,320 gallons in tanks`and containers". Complete one box for each tank or each cumulative container product tXpe. EP/Tank (2820) ❑ Containers (2821) #of Containers: T 1 Total Capacity: 4/" z } gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: Product Type: p y: ' gallons. (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: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: is ❑ Tank (2820) El Containers (2821) #of Containers: TA#: � 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: d // r Total Capacity this Page: "� Z _5 gallons Total Capacity for Site: Z gallons Comments: A EHD Inspector: Reviewed Date: Entered Date: By Initial: 0 By Initial: '`Aboveground storage tank means a tank that has the capacity to store 55 gallons or more o petroleum. ' "Container means a storage device designed to be moved when full. r. EHQ 28-01 t AST SURVEY FORM 09/12/08 e' ba