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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 /> Facility Name: ,,ccam� <br /> e I � O L Page 2 of <br /> Facilit Address: City: Inspection ate: (o y- <br /> 7Sf 5- N fir. s o �� <br /> FA#:-3 � ( � PR#: ©�j"2 Program E ement: <br /> 2 3 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*a nd containers**. <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> �1 / Zroduct Type: TAn� <br /> Total Capacity: �� I t,fI <br /> r <br /> gallons <br /> (per tank or cumulative for containers by product type) Install Date: I �`� a S 0 L�t)ei <br /> Tank (2820) ElContainers (2821) #of Containers: TA#:� 7 ✓ <br /> 2 Product Type:`rjLL �16 — �� Ik p D/2- <br /> Total Capacity: 1� D� gallons yp —� <br /> (per tank or cumulative for contai ers by product type) Install Date: <br /> Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 3 'fat/528 Product Type: TA \V- 1 64S6 14nsz 01 ( <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers byproduct type) Install Date: 17 <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: B,5)Z 7 th� <br /> 47`f3p r -Iz Product Type: TA(\V <br /> Total Capacity,-C-9—&i-0-0--6gallons <br /> (per tank or cumulative for cont iners by product type) Install Date: 9 5 <br /> Tank (2820) ❑ Containers (2821) #of Containers: ,1 TA#: A-1517AI&O <br /> 5 3CP??2n9' Product Type:TAAV- N I� — 64(A4A61 - <br /> Total Capacity: 3.q C2� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 1 a gallons Total Capacity for Site: gallons <br /> Comments: ,I/ I �J til C13 <br /> � 4n <br /> W <br /> t=9 <br /> EH D specto . _Reviewed Date: ; Entered Date: <br /> By Initial: �,;�� -� _ By Initial: <br /> Iz IN*Abovegr and 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 />