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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 />Foril'fa AI �....,• <br />luul u aLUiaga ianK means a tanK that has the capacity to store 55 gallons or more of petroleu <br />rr <br />**Container means a storage device designed to be moved when full. <br />EHD 28-01 <br />09/12/08 AST SURVEY FORM <br />. �......� .. a..nv. /✓.' <br />Page of <br />Facility Address: I ^ l <br />Cit : <br />Ins _��7— <br />p ton Date: <br />FA <br />Program le ent: <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 />Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />T, A#: _Ph Q p � <br />1 <br />Total Capacity: gallons <br />"`7 <br />^ <br />Product Type: S ke,P I GI'tA <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) El Containers (2821) <br />#of Containers: <br />TA#: L r <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: <br />TA#: 7 f /� <br />3Product <br />Total Capacity: / gallons <br />Type: <br />0 (,(,�� �� <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#:e�j <br />4 <br />Total Capacity: gallons <br />Product Type: ��� <br />(per tank or cumulative for co tainers by product type) <br />Install Date: <br />i Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: <br />5Product <br />Total Capacity: gallons <br />Type: �' �ci%1 <br />D %� Lei l <br />(per tank or cumulative for co tainers by product type) <br />Install Date: <br />Total Capacity this Page: gallons Total Capacity for Site: %i) 2, L gallons <br />Comments: <br />EHD In pe <br />% <br />Reviewed <br />By Initial: <br />Date: <br />Entered Date: <br />By Initial:N� f <br />/ l <br />luul u aLUiaga ianK means a tanK that has the capacity to store 55 gallons or more of petroleu <br />rr <br />**Container means a storage device designed to be moved when full. <br />EHD 28-01 <br />09/12/08 AST SURVEY FORM <br />