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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: City: Inspection Date:, FA#: R#: Program Elemen : 19513d33 �_ �) Tank/Container Information Complete for all sites with cumulative abovegrdund storage of petroleum 21,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 7 1 Product Type: Total Capacity: gallons n (per tank or cumulative for 6ontainers by product type) Install Date: \ Q Tank (2820) ❑ Containers (282 ontainers: TA#: B2051 7 76 2 Total Capacity: Product Type: T2C��-Q p y: f �� gallons (per tank or cumulative for containers by product type) Inst l Date: 411 ,r ❑'Tank (2820) ❑ Containers (2821) #of Containers: TA#: 7!Z 3Product Type: -�-� Total Capacity: Z 0791") gallons (per tank or cumulative or containers by product type) Install Date: y� Tank (2820) ❑ Containers (2821) #of Containers: TA,#: S_ 4 Product Type: Total Capacity: t t� gallons (per tank or cumulative for containers by product type) Install Date: t ❑ 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: gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: EnteredDate: (, By Initial: By 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 09/12/08