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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 /> /?T Page of_ <br /> Facility AddZss: Gity: Inspesti�D�atey <br /> I N t/a <br /> FA#: PR#:���D Pro�g�lran7,!~lernent:l <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 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: JUa gallons Product Type.- <br /> (per <br /> ype:(per tank or cumulative for containers by product type) Install Date: <br /> 2 Tank (2820) El Containers (2821} #of Containers: TA#: <br /> 2 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 /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (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) ❑ Containers (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: �f d gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: '� d By Initial: <br /> "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more ofpetrole4. <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09!12108 <br />