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SAN JOAQUIN COUNTY <br /> a 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 /> G S Page - of / <br /> Facility Address: City: Inspe Dat <br /> FA#: PR#: Program Element: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks* and containers**. <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 1 �� Product Type: !jn ^� <br /> Total Capacity: �() (% i gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> [J Tank (2820) 11Containers (2821) #of Containers: TA#: <br /> 2f� r <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> u,6 Tank (2820) t Containers (2821) <br /> #of Containers: TA#: fur g$g <br /> 3 �- r 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 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 Page: 0 3 j gallons Total Capacity for Site: (9gallons <br /> Comments: <br /> EHD Inspector: r Reviewed Date: Entered Date: <br /> By Initial: V,4� By Initial: <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 /> 09/12/08 <br />