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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 />Fnrilil.Alnme• <br />Aboveground oiUidye 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 />- <br />Page 0 of <br />Facility A dr s: <br />_ <br />City: <br />Inspection Date: <br />FA #: PR #: <br />Program Element: <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons <br />in tanks' and containers`*. <br />Complete one box for each tank or each cumulative container product <br />type. <br />❑ Tank (2820) Containers (2821) <br />#of Containers: L TA#: _/9.5 <br />003 <br />1 <br />Total Capacity: %, 7 5 D gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />2 <br />Total Capacity: gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />3 <br />Total Capacity: gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />4 <br />Total Capacity: gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />5 <br />Total Capacity: gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: D gallons <br />Total Capacity for Site: -72 <br />&700 gallons <br />Comments: <br />EHD Inspector: <br />Reviewed <br />By Initial: <br />DatEntered <br />rl L1:101� <br />By Initial:1 <br />r Date. <br />. A�_..____.._ <br />�+� 1 <br />�al�%/,D <br />Aboveground oiUidye 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 />