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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: Page ; of <br /> Facility Address: City: Inspection Dat <br /> 0 9' 0-/ /� ii/ o� <br /> FA#: PR#: Program Eleent: <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 /> #of Containers: 3 TA#: e,151 <br /> El\Tank (2820) �1 Containers (2821) <br /> 1 Product Type: Is-207f-z' Uf <br /> Total Capacity: /�5 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 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 /> 3 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 /> 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 <br /> ate:Total Capacity this Page: , gallons Total Capacity for Site: gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> C < By Initial: 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 />