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SAN JOAQUIN COUNTYis <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 /> CAf ONka-&- 6Page Q of <br /> Facility Address: City, Ins A'� ctiio�n ate: <br /> r I�v�J o. Lra 1(0 6 <br /> FA#: D PR#: Program Element: <br /> Ds3 a3 2 33 <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#: (9 <br /> 1 Total Capacity: I s. gallons Product Type: t:4 hr eI'L I i-6 QJ 1, <br /> (per tank or cumulative for containers by product type) 0 /i_ nl^ 1660 clrb (0 Loot <br /> Install Date: ICJI? <br /> )I' Tank (2820) ❑ Containers (2821) #of Containers: TA#: OLsr Ct&q--'3 <br /> 2Product Te: ('A- <br /> yp /j� u I j--T_ Dl 1 <br /> Total Capacity: � � Q gallons • ' <br /> (per tank or cumulative for containers by product type) Install Date: LK V'/A,6- . <br /> ,'Tank (2820) ❑ Containers (2821) #of Containers: TA#: /957J q (y <br /> 3 Product Type: / 4-v 1 <br /> Total Capacity: �� gallons —I <br /> (per tank or cumulative for containers by product type) Install Date: U N (CSLr n ti Lem w <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: 6 / q&4(�5— <br /> 4 Total Capacity: �gallons Product Type: A /-ft !Z O! <br /> (per tank or cumulative for containers b product type) Install Date: U Nl41 n <br /> Tank (2820) ElContainers (2821) #of Containers: TA#: !9 <br /> 5 Total Capacity: _?rb gallons Product Type: ) je'�e C µµ,, <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 60gallons Total Capacity for Site: gallons <br /> Comments: <br /> Gc <br /> EHDIn ector: Reviewed Date: O Entered Date: <br /> uttd By Initial: �•11•t By Initial: 3 �a D <br /> Z*Abovgreand 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 <br /> 09/12/08 AST SURVEY FORM <br />