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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 /> Page / 11 <br /> Facility Address: Inspectio `te: <br /> C? <br /> FA#: _ PR#: _ ProgramElement: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks` and containers`*. <br /> Complete one box for each tank or each cumulative container product type. <br /> ❑ Tank (2820) I. , ontainers (2821) #of Containers: TA#:: ^/ D <br /> 1 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by roduct type) Install Date: <br /> ❑ Tank (2820) ontainers (2821) #of Containers: TA#: <br /> 2 Total Capacity: Z gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date.- <br /> 0 <br /> ate:❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: (" gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: iy <br /> By Initial: By Initial: kw r <br /> Aboveground storage tank means a tank that has the capacity to store 55 gallons or more 6f petroleum. <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> AST SURVEY FORM <br /> 09/12/08/08 <br />