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a SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ti600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: IV 9T /7 Page j of Facility Address: �—� r� City: .Inspectlon ate: FA CI' PR#: :Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers`*. Com late one box for each tank or each cumulative container product!me. VTank (2820) ❑ Containers (2821) #of Containers: TA#: 15, Product Type: IF , Total Capacity: gallons (per tank or cumulative for containers byproduct type) Install Date: Q Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2Product Type: Total Capacity: gallons �---- -- - -�- (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ElContainers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install ©ate: El Tank (2820) ElContainers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: A15. C �eC,4 IS ��l Hs EHD Inspector: Reviewed . i Date: Entered Date: ' By Initial: �N ��.�1-D By Initial: � Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. **Container means a storage device designed to be moved when full. EHE 28-01 AST SURVEY FORM 09112/08