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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 /> �i Page 3 of <br /> Facilit Address: City: Inspection Date: <br /> � v <br /> FAV: PR#: Program Element: <br /> U 5L 5 5 28-3 <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 type. <br /> ❑ Tank (2820) ©''Containers (2821) #of Containers: TA#: <br /> 1 Total Capacity: gallons Product Type: � , <br /> <br /> <br /> J Tank (2820) Containers (2821) #of Containers: TA#: <br /> 2Product Type: ��i PS;\0R"�l� ��► <br /> <br /> <br /> <br /> ❑ Tank (2820) ,8 Containers (2821) #of Containers: TA#: <br /> 3Product Type: S — � <br /> <br /> <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 Type: 0) <br /> _ <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: �_ TA#: <br /> 5 Total Capacity: Product Type: tM O� 6i <br /> P Y (� 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 Inspector: TReviewed Date: Entered Date: <br /> 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 <br /> 09/12/08 AST SURVEY FORM <br />