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SAN JOAQUIN COUNTY ...i 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 Facilitye: Namn A1 MDU IO b IL0r1 Cd, �� &S Page � of—L— Facility Address: City: Impction Date: 2L1 2"( Gly V ie�l �SfoGlL�a► J /Y a FA#: PR M Pr gram Element: l ( D c-f 6 O 28 "l 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. Tank (2820) ❑ Containers (2821) #of Containers: 1 _ TA#: Product Type: NAS of ZTotal Capacity: � (per tank or cumulative for containers by product type) Install Date: U K+K:A rtM ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ 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 orcumulative for containers by prooucltype) Install Date: ❑ 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: rao gallons Total Capacity for Site: CJ gallons Comments: 0/'Z— o l )[J\ &04-L- EHD Ins actor: Reviewed Date: Entered Date: By Initial: (, th. J By Initial: bovegr and storage to k 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. EHD 28-01 /08 09/12/08 AST SURVEY FORM