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SAN JOAQUIN 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: Page of Facility Address: city: Inspection Date: FA#t' PR M Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2-1,320 gallons in tanks` and containers". Complete one box for each tank or each cumulative container product type. Tank (2820) D Containers (2821) #of Containers: TA#: _ (�17- o, � 1 Total Capacity: jyC, C) gallons Product Type: �1)/ S'6` / (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 'VContainers (2821) #of Containers: TA#: 2Product Type: % Total Capacity: � q�� gallons (per 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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: (�G gallons Total Capacity for Site: gallons Comments: EHD Ins ector. Reviewed1n, Date: Entered Date: By Initial: l�Y" 2 2� �� By Initial: 3 `AbqWeWnd storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. **C,qnWjfier means a storage device designed to be moved when full. EHD 28-01 D9/12/08 AST SURVEY FORM