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.. y <br /> 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: Page f_ Of <br /> 0 / 0" <br /> Facility Address: City: Inspectio ate: <br /> Z o <br /> FA#: PR#: Program Element: <br /> 7 5 0 01-W 5- <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers*". <br /> Complete one box for each tank or each cumulative container product tyee. <br /> 04'ank (2820) ❑ Containers (2821) #of Containers: ,TA#: <br /> Total Capacity: gallons Product Type: <br /> (per tank or cumulative for c ntainers y product type) Install Date: <br /> El Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> 11 Tank (2820) 11Containers (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 Page: gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: _ Reviewed q Date: Entered Date: <br /> By Initial: is C) ej(A 8y 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 /> II EHD 28-01 AST SURVEY FORM <br /> 0917 2108 <br />