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SAN JOAQUIN COUNTY <br /> ` QENVIRONMENTAL HEALTH DEPARTMENT <br /> . ' 600 l=ast 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 /> Facilityr <br /> Name: Page �of I <br /> Ek- -< S <br /> Facility Address: Pty: InspectioJ;Da <br /> r: <br /> FA#: <br /> PR#: Program Element: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum a1,320 gallons in tanks* and containers`*. <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) ❑ Containers (2821) #of Containers: w n T�Af#: <br /> Total Capacity: '5 00 gallons Product Type:' <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) '❑ Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (2820) ElContainers (2821) #of Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <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 Pager cxb gallons Total Capacity for Site: gallons <br /> Comments: <br /> i <br /> EHD inspector. Reviewed Date: Entered Date: <br /> By Initial: '}'�1`�� By Initial: �v v <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 AST SURVEY FORM <br /> 09/12108 <br />