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SAN JOAQUIN COUNTY 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: ' M Page __/_ of Facility Address: City: Inspectio D te- b 1�O DI I' /, FA #: PR M Prograrh E e en Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks* and containers**. 11-1 Complete one box for each tank or each cumulative container product type. ank (2820) ❑ Containers (2821) #of Containers: TA#:�f7$�/�� 1 Product Type: Total Capacity:. � Ggallons (per tank or cumulative for containers by product type) Install Date: ank (2820) El Containers (2821) #of Containers: TA#: F9,5-1 8St'DS 2allons Product Type: Total Capacity: g (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TGA#: Total Capacity: gallons Product Type: (per tank or cumulative forontainers by product type) Install Date: #of Containers: TAt#: r Tank (2820) ❑Containers (2821) 4Product Total Capacity:/' Z 0-v? gallons Type: 'Lxz (per tank or cumulative for containers by product type) Install Date: El Tank(2820) containers (2821) #of Containers: TA#: j��' 5Total Product Type: .� Capacity: p y .J gallons (per tank or cumulative for containers by product type) Install Date: gallons Total Capacity this Page:d Total Capacity for Site: ,J �� gallons J Comments: EHD Inspector: Reviewed�� ( Date: By Initial: Wt" '1,�-� Entered Date: By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleurrf. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08