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- SAN JOAQUIN COUNTY <br /> YNVIRONMENTAL 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 /> �. y' S© r✓ Page –I— of <br /> Facility Ad ress: City: Inspect �t <br /> Z S� o(RA �g .- P P <br /> FA fit: PR M Program Ele erit: <br /> Tank/Container information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks` and containers". <br /> Cam le one box for each tank or each cumulative container product e. <br /> ❑ Tank (2820) /Containers (2$21) #of Containers: <br /> 1 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install.Date: <br /> ❑ Tank (2820) YContainers (2821) #of Containers: TA#: <br /> 2L' Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> 11 Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (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 Page: / gallons. Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: p Entered Date: <br /> By Initial: VIA t'j'1 cl-d_1 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 /> 0911210B <br />