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SAN JOAQUlN COUNTY 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: � 0 .5- Page of)Q 1�1 � Facility A ress: City: Inspectio Date: FA#: PR M Progra Eiement: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum X1,320 gallons in tanks` and containers**. - Com I to one box for each tank or each cumulative container product type. r l `-.L Tank (2820) Containers (2821) #of Containers: TA#: ` 1 C3 Product Type: (51-A S Total Capacity: .--. gallons _ i� (per tank or cumulative for containers by product type) Install Date: . _ I leA e JiVA 6--O h1 Ef Tank (2820) ElContainers (2821) #of Containers: TA#: 2 Product Type:Total Ca aciy: gallons (per tank orcumultteorconrotype) Install Date: A �- V 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) El Containers (2821) #of Containers: : TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: -❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 5Total Capacity: Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: ya � A Z7 EHD Inspector: Reviewed Date: Entered Date: G By Initial: By Initial P *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 full. EHD 28-01 * AST SURVEY FORM 09/12/08 1