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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 />Aboveground storage tank means a tank that 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 AST SURVEY FORM <br />09/12/08 <br />Facility Na e: <br />O d L7 //�/�/ T �>J �/ S �/1 �/ <br />Page of <br />Facility Address: <br />City: <br />Inspectio Date <br />FA #: q r PR #: <br />l � / r'_�' <br />Progra Element: <br />Z <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in <br />tanks* and containers**. <br />Complete one box for each tank or each cumulative container product type. <br />D/ ank (2820) ❑ Containers (2821) <br />#of Containers: TA#: 55/ <br />(�) <br />cvz' <br />Total Capacity: p rgallons <br />Product Type: , <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />ank (2820) El Containers (2821) <br />#of Containers: TA#: D� <br />17Sh <br />2L� <br />Total Capacity: gallons <br />Product Type: <br />(per tank or cumulative for containers byproduct type) <br />Install Date: <br />❑ Tank (2820) LV Containers (2821) <br />#of Containers:) TA#: 7 <br />3, <br />Total Capacity: ,� gallons <br />Product Type: /'� d GA <br />d / U <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) ❑ (2821) <br />#of Containers: TA#:Containers <br />� -� <br />s <br />4 <br />/2-1/6 <br />Total Capacity:a ,.gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) WContainers (2821) <br />#of Containers: TA#: <br />5 <br />Produc Tyy01 <br />� <br />C a, <br />" <br />Total Capacity: �Ci!'^� gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this PaROL - _ N <br />gallons Total Capicity for Site:( <br />gallons <br />'(211ommen <br />� ao <br />EHD Inspector: <br />4io � <br />Reviewed Date: <br />By Initial: l l .a -C <br />Entered <br />TByInitial: <br />Date: <br />Aboveground storage tank means a tank that 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 AST SURVEY FORM <br />09/12/08 <br />