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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 Facility Name: R C M Page of Facility Address: City: Inspects ate- 1 941-6v 2 6= /- 0 FA#: PR#: Prog m Ele ent, ( O Z 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. Mli/ank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: Total Capacity: ��gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA6#: 2 Total Capacity: 3 gallons Product Type: GEIS Q 7 (per tank o(cumulative for wntainers 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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (par tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector: /'�� Reviewed Date: Entered Date: c— fv By Initial: V4 �•M' By Initial: "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. EHD 28-01 AST SURVEY FORM 09/12/08