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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 /> 1--Is,HPage of <br /> Facility Address: C'y: Inspection Date, <br /> FA#: � S PR#: Program Elemen : <br /> 51W 0 v <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 /> rank (2820) ❑ Containers (2821) #of Containers: TA#,, D,Sj`Z 9 <br /> 1 �" Product Type: <br /> Total Capacity: d t*, gallons tr <br /> (per tank or cumulative f containers by product type) Install Date: , <br /> 2'Tank (2820) ❑ Containers (2821) #of Containers: TA#: ��5 ('l Q'2L9 <br /> 2 _ Product Type: <br /> Total Capacity: > c:� e> gallons -� <br /> (per tank or cumulative for containers by product type) Install Date: <br /> E 'Tank (2820) 11Containers (2821) #of Containers: STA#: <br /> 3 Product Type: <br /> Total Capacity: Z� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> El Tank (2820) CT ontainers (2821) #of Containers: / TA#: <br /> 4 Product Type: y <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: _ TA#: O6`) `Z !2,;63 <br /> 5 Product Type: /,.&q <br /> Total Capacity: 1 -� gallons <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 Inspect Reviewed Date: Entered Date: <br /> By Initial: By Initial: I I <br /> `Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. l <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />