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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.sigov.org/ehd <br />ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />Facility Name: <br />� <br />Ch t evy-o <br />Page _�2_ of <br />Facility Address: <br />aZ8 SFs «SSon �J • <br />City: <br />-7Ya <br />Insp ction ate: <br />FA M PR #: <br />�g g <br />Program Element: <br />a C5__0q <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground <br />storage of petroleum 21,320 gallons in tanks* and containers**. <br />Complete one box for each tank or each cumulative container product type. <br />�/ <br />Ld Tank (2820) 1:1Containers (2821) <br />#of Containers: <br />TA#: O6 SCO I 4q <br />1Product <br />Total Capacity: 7.2 0 3(p gallons <br />Type: ��C��n <br />oa'4 �Zol <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: o� JCpl C3_C) ✓ <br />2 <br />Total Capacity: ?,�(,oO gallons <br />Product Type: <br />(per tank or cumulative for containers y product type) <br />Install Date: <br />Kr/Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: (' 15 ( U ( �-::5 f <br />3 <br />Total Capacity: 3c�4-/ `54 8 gallons <br />Product Type: E -f -�� <br />Q C) <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />[Y/Tank(2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: 1Q,�) 9'02 <br />4 <br />Total Capacity: 5, 008 gallons <br />Product Type: <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) M Containers (2821) <br />#of Containers: 20 <br />TA#: <br />5 <br />Total Capacity: 1.10 0 gallons <br />Product Type: [,� &f <br />tj OI I c <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: 2) 8 46::'- gallons <br />Total Capacity for Site: -7z Cos 03 Co&+ gallons <br />Comments: <br />EHD Inspector: <br />ReviewedDate: <br />Entered Date: <br />By Initial: <br />By Initial: p� <br />o <br />*nig /cnr r♦ c+nronc ♦�M <br />aL.a L__ <br />,(,- �W... .... tj' a1 a ,nLilt! ds �tr capacity to store oo gallons or more of petroleum. <br />**Co finer means a storage device designed to be moved when full. <br />EHD 28-01 <br />09/12/08 AST SURVEY FORM <br />