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�Paw SAN JOAQUIN COUNTY ` r 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 Name: Mir Page of Facility Address: City: Inspection D a 2 FA Y: fP3R M: Progra Ella nt: IF 0 o a Z Tank/Container Information Comple 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. Tank (2820) ❑ Containers (2821) #of Containers: kTA#: 1 D Total Capacity: gallons T� Product Type: / lin (per tank or cumulative far ntai ars by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TAp#: 2 Total Capacity: 2 5b gallons g Product Type: h.�/�pir/ L-4(per tank or cumulative for containers by product type) Install Date: D Af :Lis A I L-'. 4 ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (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: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: S� gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Dale:`/ By In fisc �•Yu 0�1 By Initial: 7 0'l 4 '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. EHO 28-01 AST SURVEY FORM 09/12/08