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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: �/ MAC 1-1 A ,D Q /tij /q C, 14 A V C) j9� 1 A✓ Page of Facility Address: L" r/�%�l %'cis _City: Iv1Afit 1 �Gsq Inspectioij+ r�FA #: r 7 PR %%`5r-3l P� 7 Progrpa�m Element 'OL 10- Tank/Container Information iv 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. Ei� Tank (2820) ElContainers (2821) #of Containers: TA#: 19 Total Capacity: / o 00 0 gallons Product Te: yp (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: Tek#: 624-/ 2Total Capacity: p y C) 0 gallons (� Product Type: (per tank or cumulative fof containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3Product Total Capacity: t�-r' gallons Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 C 3 --Cl 4 Total Capacity: f ,,, go gallons /11 J O (per tank or cumulative for containers by product type) Install Date: 5 Tank (2820) ❑ Containers (2821) #of Containers: TA#: ,j Product Type: `� Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: -1-7 gallons Total Capacity for Site: -z 2 o a galons Comments: �� r,/00 2 t��97JiU ; EHD Inspector: > Reviewed Date: By Initial: 1 t, ,1 l�,lQ�.,q� Entered By Initial: Date: l p/*0 -Aoovegrouna storage tanK means a tanK that has the capacity to store bb gallons or more of petroleum. **Container means a storage device designed to be moved when full. IN EHD 28-01 AST SURVEY FORM 09/12/08