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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 L of Facility Address:,,, Inspecti e: /)� 0 ' V FA #: PR M Program Element: o3or 7 7d 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. ank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: Z't' Total Capacity: Z— eer gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: ©`.� / 3� 7 7 2 Total Capacity: / gallons Product Type: (per tank or cumulative for containers by product type) Install Date: EgYiank (2820) ❑ Containers (2821) #of Containers: TA#: 3 -- Total Capacity: ( gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallonsTotal Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date:Entered Date: C By Initial: By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleu . **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08