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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 j- Facility Address: City: Inspectio Dale: a FA #: PR #: Program Eleffient Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 8� 1 �' Total Capacity: gallons Product Type: i (per tank or cumulative for containers by product type) Install Date: LU'Tank (2820) ❑ Containers (2821) #of Containers: TA#: B $� 2 Total Capacity:_� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: L�ank (2820) ❑ Containers (2821) #of Containers: T 3 Total Capacity: � gallons Product Type: ,�_ (per tank or cumulative for containers by product type) Install Date: / U% /Tank(2820) ❑ Containers (2821) #of Containers: TA#: 4 z Total Capacity: yy gallons Product Type: (per tank or cumulative for containers by roduct type) Install Date: ElTank (2820) Containers (2821) #of Containers: TA#: 5 � Total Capacity: / C� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page, To gallonsl Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: By Initial: � �.�-f� Entered By Initial: Date: L5_119 storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. t **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08