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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 Mnm <br />Hoovegrouna storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br />—Container means a storage device designed to be moved when full. <br />EHD 28-01 <br />09/12!08 <br />AST SURVEY FORM <br />Page�— <br />Facility Address:City: <br />r <br />Inspection Dat <br />awFA <br />#: PR #: <br />^��� C <br />Progra e . ent: <br />7 7 <br />Tank/Container <br />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 containerproduct- <br />type. <br />� Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#:1Q��,9OB <br />1 <br />Total Capacity: C� , �) () gallons <br />Product Type: 1A" kr <br />0� <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: <br />2 <br />Total Capacity: gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: <br />3 <br />Total Capacity: gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: <br />4 <br />Total Capacity: gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />5 <br />Total Capacity: <br />p y: gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: 0 gallons <br />Total Capacity for Site: fJ gallons <br />Comments: <br />EHD Inspector: <br />Reviewed <br />By Initial: <br />Date: <br />1W ?I �ZIC U <br />Entered Date: <br />By Initial: / <br />Hoovegrouna storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br />—Container means a storage device designed to be moved when full. <br />EHD 28-01 <br />09/12!08 <br />AST SURVEY FORM <br />