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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: A I �-A � Lilo Scr-u bif Page -�— ofl_ Facility Address: city Inspe ion Date: s. f7 (- bo"/D6 �F , S �f� � "//o FA C PR N: Program Element: 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: Product Type: IA jj1 . p y: gallons (per tank or cumulative for ontainers by product type) Install Date: U N kA1&-^ ank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: _ gallons Product Type: (per lank or cumulative for containers by product rypq �� Install Date: �,Z ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by Product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by protluct 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: gallons Total Capacity for Site: gallons Comments: EHD In ctor Reviewed Date: 1 r��, Entered Date: By Initial: l�- /`� �� By Initial _ ' I *Abovegrourld storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. l "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08