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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.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: ,• m u -) S,/ [WM5 Page j of Facility Address: City: Inspecti n Da CGID�✓ `J 1Ff FA#: PR M Program Elan? I r la zg 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. Zr'Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: gallons Product Type: U�—n (per tank or cumulative for containers by product type) Install Date: El Tank (2820) EF Containers (2821) #of Containers: STA#: 2 Product Type: /�C) 1' 0^' l Total Capacity: ZCr� gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ®'Containers (2821) #of Containers: TA#: 3Product Type: Total Capacity: 7�� gallons (per tank or cumulative for containers by product type) Install Date: Ctiank (2820) ❑ Containers (2821) #of Containers: T AAiL- 4 D 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: a gallons Total Capacity for Site: / (,() gallons Comments: o/I 31P Ll o EHD Inspector: Reviewed Date: Entered Date: By Initial: Ct•t b.� By Initial: / "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