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SAF! 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 />r,uvvegrou� u Si�iaye 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 <br />09/12/08 AST SURVEY FORM <br />1 Pl ILY IYQII <br />Page <br />—L of <br />Facility Address: City: <br />5 �= �(�-1c-16 <br />Inspection Date: <br />FA #: 2 PR #: — <br />Program Element: <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 />1 <br />Tank (2820) ❑ Conta4ners (2821 )' #of Con,tain res* f TA#: T <br />1 1�- <br />tJ <br />Total Capacity: 0--�"` /ti Pr ' <br />(per tank or cumulative for con o uct type) <br />Install Date: <br />�i^ Tank (2820) ❑ Containe'rs (2821) , #of CQ�-T" " .�') ____ TA#: — <br />11efact-Type: <br />2 <br />`*' U <br />Total Capacity: ��� <br />(per tank or cumulative for containers -by product type) Install Date: <br />#of Co tainers-: f TA#: ��/ �// �� �� <br />❑ Tank (2820) [Contain (2821) \ 1 - <br />3 <br />rtr�f� P pe: E'u e � r~ 9 <br />Total Capacity: a <br />(per tank or cumulative for contain ct type) Install Date: I <br />❑ Tank (2820) Container _(2821) "of Containers, I TA#: ' �6 <br />1� b <br />4 <br />``� "'"p'f�' _ -Odu ype: +; ►,n+5�5` otv iii - -� <br />Total Capacity: � 5 r <br />(per tank or cumulative for contain uct type) Install Date: 1 _ <br />Tank (2820) EJ Containers nerps:���� #of Co'nta4TA#: — <br />� —fir <br />5 _ , <br />+rod c ype: <br />Total Capacity: —gallons <br />(per tank .-cumulative for containers by product type) Install Date: <br />Total Capacity this Page: gallons Total Capacity for Site:, gallons <br />Comments: r, <br />Ell Inspector: TReviewed Date: Entered Dafe: <br />By Initial: �(/ �( By Initial: <br />*A L, .._ __.._� _ -- _ JQ <br />r,uvvegrou� u Si�iaye 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 <br />09/12/08 AST SURVEY FORM <br />