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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 Facility Address: Cit . Inspection gate: A.FA #: Oo 31 PR #: 6 �� Program Element: -z � j) 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. C' Tank (2820) El Containers (2821) #of Containers: TAp#: �`r, g �/D 1 Total Capacity: f- ,� � gallons Product Type: %�,C's/�/`" (per tank or cumulative for containers by product type) Install Date: ❑/ Tank (2820) ElContainers (2821) #of Containers: TA#: 2Product Total Capacity: P - gallons Type: (per tank or cumulative fo ntainers by product type) Install Date: ❑ Tank (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: o () gallons7 Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Date: By Initial: 7ntered Initial: "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum.' **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 091112M