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h 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 />PA / <br />c. <br />Page Z of � <br />Facility Address: <br />City: <br />Inspect'on te: <br />jr_ <br />�r r� <br />FA #: PR #: <br />ProgramElement: <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground <br />storage of petroleum 21,320 gallons in tanks* and containers**. <br />Complete one box for each tank or each cumulative container product type. <br />0 Tank (2820) 1:1 Containers (2821) <br />ners: TA#: <br />#of Containers: q �S <br />1 <br />Total Capacity: gallons <br />// <br />Product Type: 1ItIA. <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />ank (2820) ❑Containers (2821) <br />#of Containers: TA#: <br />2 <br />Total Capacity: gallons <br />Product Type: f�i <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />3 <br />Total Capacity: gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />4 <br />Total Capacity: gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />5 <br />Total Capacity: <br />p y: gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: gallons <br />Total Capacity for Site: gallons <br />Comments: <br />EHD Inspector: p <br />Reviewed <br />Date: <br />Entered Date: <br />1, <br />* <br />By Initial: <br />By Initial: 1/ D <br />Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br />**Container means a storage device designed to be moved when full. <br />EHD 28-01 <br />09/12/08 <br />AST SURVEY FORM <br />