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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.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: - 9G Rt A q NG7`i 'Page of FacilityAddress: City: Inspec Ion Dafe- -7— YO99 - - L,,I. Y FA#: PR#;I Pr m le t: o�a� ga, Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers". Complete one box for each tank or each cumulative container product type. lf- Tank (2820) Containers (2821) #of Containers: TA 1 El Type: Total Capacity: a- gallons (per tank or cumulative for contains by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: galleons (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: EDTank (2820) ❑-Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: `1 gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: oo-t0 By Initial: t7 B *Aboveground storage t k means a tank that has the capacity to store 55 glallons or more of petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08