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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 SURVFV FnPu <br />—. Wv UVIWUIIu OLUIdyC LanK 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 <br />09/12/08 AST SURVEY FORM <br />Facility,me: <br />�l�Pi l ill p <br />Page of <br />Facility Address: <br />d0 <br />City: <br />Inspection Date: <br />FA #: <br />PR #: <br />Program Element: <br />Tank/Container <br />Information <br />Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons <br />in tanks* and containers**. <br />Complete one box for each tank or each cumulative container product type. <br />Tank (2820) ElContainers (2821) <br />#of Containers: TA#: <br />1 <br />Total Capacity: 5 00 gallons <br />Product Type: 1� <br />Acel, <br />tank or cumulative for containers by product type) <br />Install Date: <br />��' ' <br />❑ Tank (2820) -2t ontainers (2821) <br />#of Containers: �� TA#: <br />2Product <br />Total Capacity: gallons <br />e: <br />Type: �L- , t_ Fj <br />� <br />(,�w Lip . <br />(per tank or cumulative for containers by product type) <br />J <br />Install Date: <br />❑ Tank (2820) ,EFContainers (2821) <br />#of Containers: TA#: <br />3 <br />Total Capacity: d5-� ^ gallons <br />Product Type: PYIQI VIP m ( <br />j 0 w CW <br />` <br />(per tank or cumulative for containers by product type) <br />Install Date: <br /> <br /> <br />❑ Tank (2820) Containers (2821) <br />#of Containers: I TA#: <br />4 <br />Total Capacity: gallons <br />Product Type: `2�. & <br />(per tank or cumulative for conta ner by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />5 <br />Total Capacity: gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: gallons <br />Total Capacity for Site: <br />gallons <br />Comments: <br />EHD Inspector: <br />Fpte—vievved <br />y Initial: <br />Date: <br />� 4,1%-t 4 <br />Entered <br />By Initial: <br />Date: <br />—. Wv UVIWUIIu OLUIdyC LanK 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 <br />09/12/08 AST SURVEY FORM <br />