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SAN JOAQUIN COUNTY iJ4 ENVIRONMENTAL HEALTH DEPARTMENT ] V ff 600 East Main Street, Stockton, CA 95202-3029 Y Telephone: (209)468-342'0 Fax:(209)468-3433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: � � O Page of Facility Address: City: Inspect '� � 3 auk 13 � D y" FA#: PR#: Program Element: q-,; : Tank/Container Information Complete for all sites with icumulative aboveground storage of petroleum ?1,320 gallons in tanks*and containers`. Com tete one box for each tank or each cumulative container product tXpe. Tank (2820) ElContainers (2821) #of Containers: TA#: 1 Product Type: Total Capacity: gallons (per tank or cumulative for con finers by product type) Install Date: ❑ Tank (2820) VContainers. (2821) #af Containers: � TA#: 2 Product Type: /12I Total Capacity: gallons _ (per tank or cumulative for contai ers by prgduct type) Install Date: ❑ Tank (2820) ® 'Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑:Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (282 1) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers byproduct type) _ Install Date: _ Total Capacity this Pag gallons Total Capacity for Site; :r S.5 gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By.:lnitial: �'a ��p� By Initial: D i *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. **Container means a storage device designed-to be moved when full. E EHD 28-01 1 AST SURVEY FORM 09112/08