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SAN JOAQUIN COUNTY `iia" 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: Page !of Facility Address: City: Inspectio Date: o L To p / 2�ie /e FA#: PR#: b o'2 l oZ 1st I Program T D Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 11,320 gallons in tanks`and containers". Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: eTA#: 1Product Type: Total Capacity: �j � D gallons c (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (par tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (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: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: V gallons Total Capacity for Site: /�d gallons Comments: 13 2-40 r- /IDA/ EHD tnspector: ,/ Reviewed Date: Entered Date: By Initial: By Initial: '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 09112108