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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 />1 C 1 ♦ \I <br />­&1wUl lU aLvldya idnK means a tanK tnat 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 />c...nny ll-- <br />_ � <br />Page It of <br />Facility Address: <br />City: <br />Ins action Date: <br />0-6 L.� <br />FA #: PR #: <br />� 0-2)�g <br />2-9 l l <br />PrElem <br />Element: <br />I <br />Tank/Container <br />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 />ank (2820) ❑ Containers (2821) <br />#of Containers: TA#: �9Sa D / 7 J <br />1 <br />Total Capacity: gallons <br />Product Type: � Cyk l <br />(per tank or cumulative for co tainers by product type) <br />Install Date: l <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: 19 / 7Z <br />2Product <br />Total Capacity: � gallons <br />Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: 42,6- �2 -7 <br />3Product <br />Total Capacity: gallons <br />Type: ppb/ (), <br />(per tank or cumulative for cont ners by product type) <br />Install Date: <br />Tank (2820) ❑ Containers (2821) <br />*of Containers: TA#: e5o2D J % <br />4 <br />Total Capacity: _ �1rj(�_ gallons <br />Product Type:}- 7� <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />8Product <br />Total Capacity: �, (� gallons <br />Type: Q +Ojnn 0 A <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: gallons Total Capacity for Site: gallons <br />Comments: <br />^ n <br />EHD Inspector: <br />L 41'By <br />Reviewed <br />Initial: <br />I Date: <br />�U� 1 `1 <br />Entered Date <br />By Initial: <br />b / / <br />­&1wUl lU aLvldya idnK means a tanK tnat 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 />