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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 /> (2 / �l / Page of <br /> Facility Address: City: Inspec on Date. <br /> FA#: PR#: Program Element: <br /> 7-3 2-930 <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 /> a n k (2820) ❑ Containers (2821) #of Containers: ,ZA#: <br /> 1 <br /> Total Capacity: �-0 0 gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Ell/Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Product Type: S' d ; <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> IK/Tank (2820) ❑ Containers (2821) #of Containers: TA#: B,,9 r/�3-7 <br /> 3 Product Type: �C�S <br /> Total Capacity: D gallons <br /> (per tan' umulative for containers by product type) Install Date: <br /> �t:Tank (2820) Cl 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 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 0 D gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: <br /> "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more df pe roleum <br /> `*Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />