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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:MAI N DNS 3 �° Z?/ Page of Facility Address: f Cit : Inspect! Date: z 2�" Fir A) c 1,1 GA� e G FA#: PR M Progr m E em n ?K01�53oIgt 1 2$ 30 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#: ®5f 1 C? Product Type: Total Capacity: � C�� gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Q.A� Total Capacity: ® gallons (per tank or cumulative for containers by product type) Install Date: �Tank (2820) ❑ Containers (2821) #of Containers: TA#: f�/�f,'IZ35 ?12- 3 Product Type: �q/A 6�Tr O r L/ Total Capacity: gallons (per tank or cumulative f r 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: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: Z— gallons Comments: /lJ �✓ EHD Inspector: Reviewed1• `' Date: Entered Dat ke: By Initial: ,`A ,1� g� By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. IY **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08