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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: l� <br />Page of <br />Facility Address: City: In"ctlon Date: <br />FA #: 1oo �. <br />Co p C/ T Program Element: <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 />L.'J Tank (2820) ❑Containers (2821) <br />#of Containers: TA#:/ Cp O <br />1 <br />Total Capacity: � t, , GOO Product Type: gallons � u &,e c) � <br />(per tank or cumulative for containers by product type) Install Date: <br />neviewea uate: Entered Date - <br />By <br />By Initial: jo By Initial: '1 <br />ndstorage tan Bans 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 <br />AST SURVEY FORM <br />Cl'Tank (2820) ❑ Containers (2821) <br />*of Containers: <br />TA#: 25A _q <br />2 <br />I <br />Total Capacity: /(,, �' C CJ gallons <br />Product Type: <br />Per tank or cumulative for containers by product type) <br />Install Date: <br />C�Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TAM 06_2_z2 21 <br />3 <br />Total Capacity: /� �% �: gallons <br />Product Type: <br />(per tank or cumulative for c ntainers by product type) <br />Install Date: <br />2I/Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: <br />4 <br />t <br />Total Capacity: ��� gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) Ercontainers (2821) <br />#of Containers: (OTA#: B<5a 66 3 <br />5 <br />Total Capacity: , ��C� �� gallons <br />Product Type: <br />�/ / 1-2161 t .,- <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: c (J <br />gallons Total Capacity for Site: gallons <br />Comments: <br />G/n"P?� n <br />neviewea uate: Entered Date - <br />By <br />By Initial: jo By Initial: '1 <br />ndstorage tan Bans 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 <br />AST SURVEY FORM <br />