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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: _ ty: Inspectio Date: FA #: PR #: Program le ent: 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#: 1 Product Type: Total Capacity: gallons (per tank or cumulative for containers Ey product type) Install Date: NJ Tank (2820) ElContainers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) —1 Containers (2821) #of Containers: TAS: 3 - Product Type: . Total Capacity: _ gallons -- (per tank or cumulative t.. wntainers 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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: D c) gallons Total Capacity for Site: gallons Comments: EHD Inspector: ` Reviewed Date: Entered Date: By Initial: By Initial:P'/'?do -Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleufn. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/1;)/()B