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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.sigov.org/ehd <br />ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />Facilifv Almm�• <br />Ab gr and storage tan means a tank that has the capacity to store 55 gallons or more of petroleum. <br />*Con -Winer means a storage device designed to be moved when full. <br />EHD 28-01 <br />09/12/08 AST SURVEY FORM <br />Page o of Z <br />Facility Address: <br />City: <br />%7W <br />Inspect on Date: <br />t <br />FA #: PR #: <br />3-Aol <br />®5/822 <br />0� OCD <br />Program Element: <br />090- <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum 2,1,320 gallons in tanks` and containers". <br />Complete one box for each tank or each cumulative container product type. <br />C] Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: per/ (v9� <br />1 <br />Total Capacity: C7 <br />p y: gallons <br />Product Type: -/ <br />" <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />BTank (2820) 11 Containers (2821) <br />#of Containers: TA#: OS/Co9 <br />2 <br />Capacity: 45 D <br />Total y: gallons <br />p <br />Product Type: .�i.e, q r - <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ® Containers (2821) <br />#of Containers: 5 TA#: Q!53 95� <br />3 <br />Total Capacity: z,.2 % `� gallons <br />Product Type: 6I S ec-11 OO <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) Lt Containers (2821) <br />#of Containers: _� TA#: _05/fv955� <br />4 <br />Total Ca acity: 0'_30 gallons <br />Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />M Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: 6 5/4o 95C / <br />6Product <br />Total Capacity: q7 1710 gallons <br />Type: /�% 0 V k— O/' <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: J, 5 gallons <br />Total Capacity for Site: cl� �2 �5 gallons <br />Comments: <br />✓f 05 2-- — <br />-/� o> � <br />� � 7 �'Z.I�S-' <br />�7i �D�d� �✓��. <br />rdQ 5 <br />EHD In ctor: <br />* <br />Reviewed Date: <br />By Initial:10,k5-t J <br />Entered Date: <br />By Initial: iD p <br />cc 7 !!� <br />Ab gr and storage tan means a tank that has the capacity to store 55 gallons or more of petroleum. <br />*Con -Winer means a storage device designed to be moved when full. <br />EHD 28-01 <br />09/12/08 AST SURVEY FORM <br />