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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: <br /> C r-0ott S i r>e,, �D u� h �il�� Page 4— of <br /> Facility Address: City: Inspection Date: <br /> ( �3 p vGL l ( Id 5 <br /> FA#: D '1 PR M — Program Element: <br /> V 1 293 <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 /> l Tank (2820) ❑ Containers (2821) #of Containers: <br /> 1 Total y: gallons <br /> Capacity: 608 Product Type: <br /> p <br /> (per tank or cumulative for containers by product type) Install Date: L e-) <br /> 1 Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: S_6 U gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: - / J4-7 <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Product Type: ���- b I Z. <br /> Total Capacity: gallons <br /> (per tank or cumulative for ontainers by product type) Install Date: pl cj <br /> ElTank (2820) ,Containers (2821) #of Containers: ' I� TA#: 5sa <br /> 4 0 Product Type: t`i Q/�1i l/Z OIL <br /> Total Capacity: �� gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) Containers (2821) #of Containers: TA#: <br /> 5 Product Type: �� ' �_1 L /S- <br /> (per <br /> r' �d <br /> Total Capacity: � gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: 2��� gallons <br /> Comments: <br /> EHD In ector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: <br /> 16 <br /> *Abovegrou d storage tank means a tank that has the capacity to store 55 ga Ions or more o 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 />