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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 /> E N G Page�L of <br /> Facility Address: City: Inspect) te: <br /> FA k: PIR F: Program Elem t: <br /> _ p <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 11,320 gallons in tanks`and containers". <br /> Complete one box for each tank or each cumulative container product type. <br /> g,A-Iank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Total Capacity: 2- 5-0 gallons Product Type: GQ JgZ <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ nk (2820) ❑ Containers (2821) #of Containers: TA/#: <br /> 2Product Type: (J v rf 7 <br /> Total Capacity: ZT�) 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 /> ❑ 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) ❑ 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: gallons Total Capacity for Site: gallons <br /> Comments: <br /> Z <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: 00.11, By Initial: <br /> "Aboveground storagelank means a tank that has the capacity to store 55 gallons or more o petroleum. <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />