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SAN JOAQUIN COUNTY t ?NVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov./SURVEY d ABOVEGROUND PETROLEUM STORAGE PROGRA FORM Fa'ty Name: Page of Facility ddress: City: Inspection Date: FA #: PR #: Program Element: Tank/Container Infornapfion Complete for \all' with cumulative aboveground storage of petroleum V320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumuldive container product type. ❑ Tank (2820\conta tainers (2821) #of Cont ers: TA#: (>250 gallons)s and <250 gallons) 1 Produc ype: Total Capacity:gallons (per tank or emulativeby product type) Inst Date: ❑ Tank (2820) ❑ Con\ers(2�821)/Install Containers: TA#: (>250 gallons) (>55 gallosduct Type: Total Capacity: (per tank or cumulative for container Date: ❑ Tank (2820) ❑ ContainA)#ofntainers: TA#: (>250 gallons) (>55 gallons an3 t Type: Total Capacity: (per tank or cumulative for containers by p Date: ❑ Tank (2820) ❑ Cont ' ers (282 1) #of Co\Date: TA#: (>250 gallons) (>55 gall o and Q50 gallons) 4 Produc Total Capacity: gallons (per tank or cumulative for con ers by product type) Install ❑ Tank (2821>55 Containers (2821) #of Containers: TA#: (>250 gallons) gallons and <250 gallons)5 Product Type: Total Capacit gallons Install Date: (per tank or comuttainers by product type) Total Capacity this age: gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: EHD 28-01 01/16/08