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i 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 /> Facility Name: <br /> of C-4w C O hco,­l D f 1Y)� , Page ';�5 of <br /> Facility Address: 2 Cit • in Ion ate: <br /> FA PR MProgram Element- <br /> 0 s_-:5 0.2-31 a <br /> lement:Os_-:5o02a <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) *of Containers: TA#: a D( �a <br /> 1 5 c C <br /> Total Capacity: .jgallons Product Type: <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> l Tank (2820) ❑ Containers (2821) #of Containers: TAM i96a p J ZC <br /> 2 Product Type: psi o ,� C <br /> Total Capacity: �O O gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank orcumulaaveformniainers by producttype) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> Total Capacity this Page: 0 O gallons Total Cacit capacity Y for Site: /., Q(P t1) gallons <br /> Comments: <br /> ERE)Ins edor: Reviewed /^,��`�1 Date: 1 Entered Date: <br /> By 11 ial: Vw M 1 `� By Initial: <br /> "Aboa Gnd storage tank means a-tank that has the capacity to store 55 gallons or more of petroleum. <br /> ainer means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />