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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.sigov.org/ehd <br />ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />Facilit Na <br />elvW"U awia9C LanK means a tanK that has the capacity to store 55 gallons or more o 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 />y me. <br />Page ( of <br />Facility Address: <br />?--2- ; i l �2.11 S� <br />City: <br />2� lni✓ /\J <br />Inspection Date: <br />`01 (-Z Z 1 ( o <br />FA #: PR #:Program <br />ooa9i4--7 1 <br />—T <br />Element: <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground <br />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: TA#: Q�j99o,� <br />1 <br />Total Capacity: � Q�j � gallons <br />Product T 17 (� Q 6-A <br />Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: 2 61� , <br />1 Tank (2820) ElContainers (2821) <br />#of Containers: TA#: <br />2Product <br />Total Capacity: 5-00 gallons <br />Type: Uscd cl <br />(per tank or cumulative for containers by product type) <br />Install Date: Ci 5 <br />Z Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: 19 6-1 29 7- <br />3 <br />T-"- '" <br />Total Capacity: 1 SZ, gallons <br />L, rod uct Type: 7 i C S <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) '4, Containers (2821) <br />#of Containers: 3 TA#: S,6-1 <br />4 <br />Total Capacity: 1 (,- � gallons <br />r - <br />Product Type: n s, r ��' �'DIO w tILL �4d l i , <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: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: I gallons Total Capacity for Site: ( gallons <br />Comments: <br />" <br />EHD Inspector:Reviewed <br />G� n(02 <br />Date: <br />By Initial: <br />Entered Date: r/ J <br />By Initial: <br />I <br />elvW"U awia9C LanK means a tanK that has the capacity to store 55 gallons or more o 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 />