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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: r <br /> d 3 �� I^ Page 1— of <br /> Facility Address: City: Inspection D t /t] <br /> FA#-. PR M Program Elem <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks*and containers**. <br /> Complete one box for each tank or each cumulative container product type. <br /> ank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Total Capacity: C7j2 gallons Product Type: <br /> (per tank or cumulative for containers byproduct type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> r 2 Total Ca acit Product Type: <br /> p y: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> E] Tank (2820) L1Containers (2821) #af Containers: TA#: <br /> 3 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) 'Install Date: <br /> ❑ Tank (2820) ElContainers (2821) #af Containers: TA#: <br /> S Total Ca acit Product Type: <br /> p y: gallons <br /> (per tank or cumulative for containers byproduct type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> / By Initial; vtj 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-Oi AST SURVEY FORM <br /> D9112108 <br />