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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 /> R 18 Page / of l <br /> Facility Address: City: Inspection Date: <br /> FA#: PR#4� Program Element: <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 2:1,320 gallons in tanks"and containers'". <br /> Complete one box for each tank or each cumulative container product type. <br /> 2reTank (2820) ❑ Containers (2821) #af Containers: TA#: <br /> 1 Product Type: <br /> Total Capacity: 41 a gallons -- <br /> (per tank or cumulative for containers byproduct type) <br /> Install Date: <br /> .❑ Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 2 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ElTank (2820) E1Containers (2821) *of Containers: TA#: <br /> 3 <br /> .Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> .-❑ Tank {2820) ❑ Containers (2821) #of Containers: "' TAM <br /> 4 Product Type: <br /> Total Capacity: gallons °••• <br /> (per tank or cumulative for containers by product type) Install bate: <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: 0-0 gallons j Total Capacity for Site: t3� gallons <br /> Comments: <br /> EMD Inspector: Reviewed Date: Entered Dat <br /> tet/, By Initial q.q6A By Initial: L/l <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more petroleum. <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> vs/t 2roa <br />