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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN" 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 Name: 9koW A N 0 Page of Facility Address: City Ins e: e: 99t �VooD WA(� P AW FA#: O O �.y PR�/� Program Element: g ' • �, U .`7{ � 2, Lit,' Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capaity: gallons (per tank or cum ative for containers by product type) Install Date: ❑ Tank (2820 ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: gallons (per tank or cumulative f containers by product type) Install Date: ❑ Tank(2820) Containers (2821) #of Containers: TA#: (>250 gallons) (> gallons and<250 gallons) 3 Product Type: Total Capacity: gallons (per tank or cumulative for con ers by product type) Install Date: ❑ Tank(2820) ❑ Co tainers (2821) #of Containers: TA#: (>250 gallons) (>55 gall s and<250 gallons) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers b product type) Install Date: ❑ Tank (2820) ❑ Contai ers (282 1) #of Containers: TA#: (>250 gallons) (>55 gallons an <250 gallons) 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: N� EHD Inspector: Reviewed Date: ,I Entered Date: By Initial: �, ��b By Initial: EHD 28-01 01/16/08