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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 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 Nine: 04d Page of Facility Address:�/ ��77 City: 9 7 Inspecttiio 4 tt FA M PR M Program Eleme Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. �nk (2820) ❑ Containers (2821) #of Containers: TA#: �/ cd B 1 0 Product Type: Total Capacity: O U gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: ank (2820) ElContainers (2821) 2 Total Capacity: Product Type: /', Q f �� gallons —�— (per tank or cumulative for containers by product type) Install Date: #of Containers: L- TA#: EITank (2820) aContainers (2821) 3 Product Type: Total Capacity: gallons per tank or cumulative for containers by product type) Install Date: #of Containe, TA#: _. ElTank (2820) Containers (2821) 4Product Total Capacity: Type: :2 o 7a /L-- gallons (per tank or cumulative for containers by product type) Install Date: Er Tank (2820) El Containers (2821) #of Containers: TA#: ("q I/ -'Tank 5 Product Type: Total Capacity: ��/� gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 0 gallons Total Capacity for Site: , 4 �gallons Comments: EHD Inspector: y Reviewed Date: By Initial: Entered Date: 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. EHD 28-01 AST SURVEY FORM 09/12/08