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bl- 5 fir SAN JOAQUIN COUNTY y ENVIRONMENTAL HEALTH DEPARTMENT 600 last Main Street, Stockton, CA'95202-3029 Telephone; (209) 468-3420 Fax.(209) 46$_3433 Web: www.sjg0v.org/ehd ABOVEGROUND PETROLEUM STORAGE P ROGRAM SURVEY FORM Facility Name: r U `� IoM q'V-1 L q Facility Address:t> Page [ of 1 FA M pes(,`M5 AVQ- , city: �L Inspe ion t]a e: `` PR#: 2 3 D,f5 a Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petrole!6' t 21,320 gallons in tanks"and containers**. Complete one box for each tank or each cumulative container product t e. 7 Tank (2820) ❑ Containers (2821} #of Containers: TA#: i Type.- _C2�< In Q., Total Capacity: .�U0 gallons Product Tvi -o"tank or cumulative for containers by product type) Install Date: U Ny -o" ❑ Tank (2820) Containers (2821) #of Containers: TA#: i 2 Product Type: C>/-Z- (per Total Capacity: � (, gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821} *of Containers: _t TA#: 3 -rte Product Type: l�` ��.t 4-U Total Capacity: J gallons • _ (per tank or cumulative for containers by product type) Install Date: 1 ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Tota! Capacity: gallons (per tank or cumulative for containers by product type) Install Date: M k ❑ Tank (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: S gallons Total Capacity for site: ��1 gallons Comments: I G ! EHD tnspe Reviewed Date: Entered Date: F By initial: ';y'�.p 0l By Initial: - *Aboveground torage tank me ns 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 I 09112108