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SAN aJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTENT 600 East Main Street, Stockton, CA 95 02-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: _ IWC) MA� � S / � �� F,� %�R6 � Page r of Facility Address::? city: Inspec ion Da : /vl.�T3110 FA #: PR #: Program EI, men Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: P�SJ 7 7& 0 1 Total Capacity: � gallons Product Type: ;?-t' j2- "fl (per tank or cumulative for containers by product type) Install Date: Ld Tank (2820) ❑ Containers (2821) #of Containers: -TA#: 6:1-7 7 IP 2 Product Type: y~?� Total Capacity: ?� ©� �' gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: El Tank(2820) ElContainers (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: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: --� f " , ! �y gallons Total Capacity for Site: �� i gallons Comments: EHD Inspector: ! ; Reviewed Date: By Initial: vj� Entered Dater By Initial: cJ D *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