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ILI <br />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 RIIPVI=V rnluee <br />.._ _ - _�. _.,.,,.,'V- ,,,,,,� , , iia„O a tai in a iat i las Litee 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 />Facility Name: <br />Page _2_ of: <br />TQw <br />Facility Address: <br />City:_ <br />Inspection Date: <br />r�{G(r <br />FA #: PR #:q <br />l U <br />Program Element: <br />I <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 <br />product type. <br />[9 Tank (2820) Containers (2821) <br />#of Containers: <br />TA#: C1 <br />1 <br />Total Capacity: gallons <br />Product T e: <br />yp - <br />t <br />' r, LEL, T�1 ._ <br />(per tank or cumulative for rftain`ers by product type) <br />Install Date: <br /> <br />le <br />Tank (2820) kContainers (2821) <br />#of Containers: <br />TA#:2,5- <br />2 <br />' Yotal Capacity: (� C gallons <br />Product Type: <br />-411 — d - <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />�' <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />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: <br />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: <br />p y: gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: <br />gallons <br />Total Capacity for Site: gallons <br />Comments: <br />v&Q VA-rI6 "nom 14 - <br />d -J ?AtnC, _M <br />fl-f-_-PLC-� fgC5E CA -W kcn > <br />S�{ W►� 1 z -rlkr• -s , <br />To W4- vv'-.. r^t <br />sT*,4 S 1-tt-, 5AYAf . <br />EHD Inspector: <br />I Cl <br />Reviewed Date: <br />By initial: � Lt �6 t� <br />Entered Date: <br />By Initial: <br />*Abovanro inrl ctnrn— f�..11 m ♦ �, <br />4" a l-__ aL_ <br />.._ _ - _�. _.,.,,.,'V- ,,,,,,� , , iia„O a tai in a iat i las Litee 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 />