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ft 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: i M Page Facility Address: City: Inspec�pD e 2 S Mz j FA #: PR #: Program EI nt 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. 1 Tank (2820) ❑ Containers (2821) #of Containers: TA#: Total Capacity: L D a gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Ear Tank (2820) ❑ Containers (2821) #of Containers: TA#: /9 51$ (g5,f 2 Total Capacity: g �� gallons Product Type: A5 -n �S (per tank or cumulative for containers by product type) Install Date: UTank (2820) ❑ Containers (2821) #of Containers: TA#: 3Ir Total Capacity: 'Q gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: Rc� 1 L 4 Total Capacity: gallons for iners by Product Type: (per tank or cumulative cont pro ct type) Install Date: R Tank (2820) El Containers (2821) #of Containers: STA#: �'S 5 Total Capacity: y jj 00 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons U0, Comments: EHD Inspector: Reviewed Date: p By Initial: �.�0 O 1 Entered Date: By Initial: �7l "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