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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: <br />j- � E � ��- . cf-,,_ 4 k l Al-., . r --Tk-7 n I Paae i of �— <br />-- -� -- - 'I- • "' �G a weir' uiaL iiaa LIiC CcRdcity to store 55 gallons or more of petroleum. <br />**Container a a storage device designed to be moved when full. <br />EHD 28.01 <br />09/12/08 AST SURVEY FORM <br />Facility Address: <br />City: <br />Inspectio 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 in tanks* and containers`*. <br />Complete one box for each tank or each cumulative container product type. <br />XTank (2820) ❑ Containers (2821) <br />#of Containers: TA#: aQ ,21-9 �1 <br />1 <br />Total Capacity: c-,;2 7 gallons <br />Product Type: ag-'Od q/'/ <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: a7'gallons <br />Product Type: Al ol-o� O/ <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: Du�o2D�D� <br />3 <br />Total Capacity: / D Q 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: /0D gallons <br />qq <br />Product Type: tet b7�r DI <br />/ <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: _( 107D V Q/ <br />(per tank or cumulative for c ntainers by product type) <br />Install Date: <br />Total Capacity this Page: C) gallons <br />Total Capacity for Site: gallons <br />Comments: <br />EHD Inspector: <br />Reviewed <br />By Initial: <br />Date: <br />Entered ate: <br />By Initial: <br />*AhnvPnrniinH Qfnr=AL f—L- <br />_ <br />-- -� -- - 'I- • "' �G a weir' uiaL iiaa LIiC CcRdcity to store 55 gallons or more of petroleum. <br />**Container a a storage device designed to be moved when full. <br />EHD 28.01 <br />09/12/08 AST SURVEY FORM <br />