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r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility NameC—Mif N441: GL. Page ` of Facility Address. f �I^ `r. City: Inspe tion D e: FA#: PR : �'�� Program Element: 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. ❑ Tank (2820) ET Containers (2821) #of Containers: 1 TA#: �/J,�'� 1 Product Type: CLZ�i1(i a T ity: �u gallons (per tank or cumulative for iners by product Install Date: I- 1 ❑ Tank (2820) ❑Containers (2821) #o - - ' (per tank or cumulative for containers by product type) L 6 Cbl ,tyt. Install Date: ❑ Tank (2820) ❑ Containers (2821) #of C TA#: 3 '11 Product Type: oia Total Capacity: I V gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 216 ontainers (2821) #of Containers: _� TA#: 4Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) &a Install Date: tivyl ❑ 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: 7 s gallons Total Capacity for Site: -7 S gallons Comments: EHD Ins r: Reviewed Date: Entered Date: S-by By Initial: By Initial: *Ab69vound storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. O "Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM