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• SAN JOAQUIN COUNTY 0 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: L u bt /Lf Page j of Facility Address: I r I City: Inspection Date: FA#: FR#: ProgrraampE�lement: -2-77 4K 0S2-2 14, Ii OJ 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. .E� Tank (2820) ❑ Containers (2821) #of Containers: TA#: US 161E�F 1 Product Type: l-As4 - <>,' ( Total Capacity: /po O gallons (per tank or cumulative forcontainers by product type) Install Date: Zoo Lt .F7" Tank (2820) ❑ Containers (2821) #of Containers: 2 Total Capacity: 7,3o gallons Product Type: 7')= (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: OSI b -�4 1 3 Total Capacity: 7"3 a gallons Product Type: w w -y o (per tank or cumulative for containers by product type) Install Date: R Tank (2820) ❑ Containers (2821) #of Containers: TA#: b5 ir(o t(-so 4 Total Capacity: 2-' 3o gallons Product Type: 57W (per tank or cumulative for containers by product type) Install Date: R Tank (2820) ❑ Containers (2821) #of Containers: TA#: 05116 457 t 5 Total Capacity: Z30 gallons Product Type: SL-) - 3o roar o; / (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Z O gallons Total Capacity for Site: (�p gallons Comments: EHD Inspector: t Reviewed Date: Entered Date: 6 3 By Initial: By Initial: *Abov gr nd storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. **Cont er means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 08/12/08/08