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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'kaA4 ������� ^�( ��Op Page / of Z <br /> Facility Address: city: Inspe tion Date: <br /> r'J�O S• HW!a �z� <br /> FA q. PR 9: Program Element: <br /> /00&58 O <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 11,320 gallons in tanks`and containers". <br /> Complete one box for each tank or each cumulative container roduct type._ <br /> XTank (2820) El Containers (2821) #of Containers:-—_ TA#: O <br /> 1 Total Capacity:-0 0 gallons Product Type: 0 74 k- 00 <br /> per tank or cumulative for containers by product type) Install Date: leo <br /> Tank (2820) El Containers (2821) <br /> #of Containers: TAM _btt5 o2Dl/o <br /> 2 Total Capacity: 2 0 Dgallons Product Type: /U O 7L-0'D ` 197-1 <br /> (per tank or cumulative for containers by product type) Install Date: <br /> XjTank (2820) ❑ Containers (2821) #of Containers: TA#: 15Fi <br /> 3 Total Capacity: 20 0 gallons Product Type: _A4Q/DY a.7'1 <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TAM <br /> A � <br /> 4 Total Capacity: '41? 0gallons Product Type: <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> El Tank (2820) Containers (2821) #of Containers: TAM -a D <br /> 5 ` Product Type: <br /> Total Capacity: 'gallons <br /> (per tank or cumulative for containers byproduct type) <br /> Install Date: <br /> Total Capacity this Page: az5 / 30 gallons Total Capacity for Slte: &6 � 1 PJ gallons <br /> Comments: <br /> 5s' S o� <br /> fee <br /> EHD ect : Reviewed Date: Entered Date: <br /> By Initial: J'h 1 t, By Initial: ,(� .� <br /> "A v round storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. L <br /> "06fitainer means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />