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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 Narpe: MoC Page of 4 M Facility Addre City: Inspectio Date: llkzlveay FA#: L, PR#: Program Ele ent 5 �g� --7 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#: '� 1 Total Capacity: Z O Z7 gallons Product Type: f7�o (per tank or cumulative for containers by product type) Install Date: [!�'Tank (2820) ❑ Containers (2821) #of Containers: TA#: h 1 �z 2 Product Type: Total Capacity: 2 G-t!) gallons (per tank or cumulative for containers by product type) Install Date: LZ Tank (2820) ❑ Containers (2821) #of Containers: TA#: `7 3 gallons Product Type: du Total Capacity: IP PV g (per tank or cumulative for containers by proct type) Install Date: L�Tank (2820) El<— (2821) #of Containers: TA#: o�/ �] 4 Product Type: s 0 Total Capacity: <� gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: 5 J"f�� Product Type: �Af Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: ZI 010 gallons Total Capacity for Site: —Z_ Z� gallons Comments: EHD Inspector: Reviewed t Date: Entered Date: By " Initial: �V a,�j- 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