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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 />' WuY � awl aya Ld11K means a tank that has the capacity to store 55 gallons or more of petroleum. <br />**Co ainer means a storage device designed to be moved when full. <br />EHD 28-01 <br />09/12/08 AST SURVEY FORM <br />racnny rvame: L" V f <br />Ili �;)� %� 0 <br />Page of <br />Facility Ad ress: <br />City: <br />Inspection Date: <br />DL� M <br />l�-' <br />FA #: PR i <br />Pro Element: <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 />Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: z9, -S7 9•'TD 3 <br />1 <br />Total Capacity: <br />p Y� 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#: %% 19 70 <br />2 <br />e <br />otal Capacity: gallons <br />! <br />1� <br />Product Type: 5W��I, l�1 <br />(per tank or cumulative for containers by product type) <br />Install Date:.% <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: l gallons <br />Product Type: /�1�1 �,� <br />,� oil <br />(per tank or cumulative for containers by product type) <br />Install Date: UA/11 <br />V Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: _ <br />5Product <br />Total Capacity:q] q gallons <br />Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: 2 gallons Total Capacity for Site: 3kgallons <br />Comments: <br />EHD Inspecto <br />Reviewed <br />By Initial: <br />Date: <br />•15` (� <br />Entered Date: <br />gy Initial: <br />' WuY � awl aya Ld11K means a tank that has the capacity to store 55 gallons or more of petroleum. <br />**Co ainer means a storage device designed to be moved when full. <br />EHD 28-01 <br />09/12/08 AST SURVEY FORM <br />