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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT "960 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: Lovi -S A66A Page —L—of Facility Address: City: Ins'71,77o ectio Date- 01 �= GAM a /7C AM ��f,7o 8 FA#: PR#: Program Element: 7- S3o Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: /000 gallons (per tank or cumulative for containers by product type) Install Date: ti/Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: SoD gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: /5'0 b gallons Total Capacity for Site: /.I—D D gallons Comments: EHD Inspector: J Reviewed 1 Date: ./ Entered Date: By Initial: 1,arl ,,.�•OD By Initiate EHD 28-01 ver'- 01/16/08