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P 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 Na Page of Facility Address: City: Inspection Date: 5 - z�- FA#: PR M Program Element: - �Z Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum X1,320 gallons in tanks*and containers". Complete one box for each tank or each cumulative container product type. ❑ Tank (2820) Containers 1) #of Containers: TA#: 1 S3Product Type: l Total Capacity: � gallons (per tank or cumulative for containers by product type) Install Date: ct-mr"-. -" ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers 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: S gallons Total Capacity for Site: gallons Comments: EHD Ins pe r: ReviewedDate: Entered Date: By Initial: �lJ 1" Qv, ( By Initial: *Abov ground 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 09/12/08 AST SURVEY FORM