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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 /> MACl'1AbQ it-InC14AVC) PRlAY Page of <br /> Facility Addres • City: Inspectio Dat <br /> 6 s�2` - ��R �l � R� MAnr 1 gosq Io)J� D <br /> FA#: PR Program lament: <br /> / / J— n7 D'5�ID� � 6 <br /> / <br /> Tank/Container Information Wle <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers". d <br /> Complete one box for each tank or each cumulative container product type. <br /> G}'Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 d 00 0 Product Type: <br /> Total Capacity: /' gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: c3 <br /> 2 Total Capacity: 0 0 0 gallons Product Type: n o <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TAM <br /> 3 Total Capacity: �gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ElContainers (2821) #of Containers: TA#: ! <br /> q Product Type: /3 G <br /> Total Capacity: / ,�gY7 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: T <br /> 5 Total Capacity: �gallons Product Type: S <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: ZZ d� gallons Total Capacity for Site: 2 Z o(� gal ons <br /> Comments: G1jkl( I �AG���y�, <br /> 2v S'31 ���97 v l <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> ,, , <br /> By Initial: 11 `o,�, By Initial: IO �O <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> **Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09/12/08 <br />