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' SAN JOAQUIN COUNTY <br /> 1 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 /> C O T T A �lr n 1%l/�A PA/12 � Page —1_ofL— <br /> Facility Address: City: In pe tion Da e: <br /> FA#: PR#: ra <br /> Pro m EI an <br /> �; <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 /> er-Tank (2820) ❑ Containers (2821) #of Containers: _1 TA D 25 <br /> 1 Product <br /> Total Capacity: G d) Vgallons Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: /95 f g'g3 a <br /> 2 Product Type: _ � <br /> Total Capacity: I 0 0-0 gallons <br /> L2 <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: <br /> 3 Total Capacity:y /G�� gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ank (2820) El Containers (2821) #of Containers: TA#: ��� <br /> 4 Product Type: � L <br /> Total Capacity: 50gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: TA#: Dom) %-V �— <br /> 5 Product Type: /V <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: �l ` gallons Total Capacity for Site: �,I gallons <br /> Comments: <br /> EHD Inspector: Reviewed ` Date: Entered Date: <br /> By Initial: t �•'>7�• By Initial: <br /> *Aboveground 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 />