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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 U z ! U -4 A Al N C- 3 g—3 Page of Facility Address: City: Inspe do Dal e: O I PS00 �C. s�lJ 2 a 61 FA C PR#: Program EI t: b)6-31) � ' 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. WTZank (2820) ❑ Containers (2821) #of Containers: T B 1 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: [! nk (2820) El (2821) #of Containers: TA#: Ta 2Product Type: (/ .Total Capacity: � gallons (per tank or cumulative for containers by product type) Install Date: EV�Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: -( a gallons Product Type: (per tank or cumulative for containers by product type) Install Date: LH'Tank (2820) ❑ Containers (2821) #of Containers: TA#: b 0 4 �— Product Type: Total Capacity: � l� gallons �, � �//�!��J ,,, / (per tank or cumulative for containers by product type) Install Date: �0 J 5 " � v v� Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: /il"z — 7: O� Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: o gallons Total Capacity for Site: ©-o'el gallons Comments: x� v Z f LSO ' Q -;�- DT c� Gr< Ti1--� EHD Inspector: ` Reviewed Date: Entered Date: By Initial: �,0 By Initial: Le B *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more c petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08