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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: FA fi M -S Page of Facility Address: Cit Inspect'. FA#: PR M Program Element: I o --3 -2-f3 19 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) ❑ Containers (2821) #of Containers: TA#: ©,61 '7iSo2�' 1 Product Type: lip► Total Capacity: (�() gallons (per tank or cumulative for cornalners by product type) Install Date: L,YTank (2820) ❑ Containers (2821) #of Containers: TA#: 47,6-1 -7 T; !� 2 Total Capacity: !2-" gallons Product Type: I✓A-e'-� (per tank or cumulative for containers by product type) Install Date: /Tank (2820) ❑ Containers (2821) #of Containers: —� TDA#: _ 156-1-7q,,39) 3 Product Type: Total Capacity: o gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: T #: �6-17 gc3/ 4 Product Type: Total Capacity: �� gallons (per tank or cumulative for cotftainers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: 5Product Type: Ai — Diy Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: fj gallons Total Capacity for Site: / 7 gallons Comments: EHD Inspector. Reviewed Date: Entered Date: By Initial: g-5•t� By Initial: l "'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