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t 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 /> 4 L /J r 0 t Page of <br /> Facility Address: :CitInspectio Date: <br /> FA#: PR#: Programement: <br /> 00 <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 /> [`Tank (2820) ❑ Containers (2821) #of Containers: TA#: D <br /> 1Product Type: /4//- �� l <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 /> 2 Total Capacity: Product Type: <br /> p y: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 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 /> 4 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 /> 5 Total Capacity: Product Type: <br /> p y: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: L_ gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: /� Reviewed Date: Entered Date: <br /> By Initial: By Initial: 02 <br /> `Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. 0 <br /> *"Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />