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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: S Lu 6 (C-e Page-',2- of 3 Facility Address: City: Inspection Date: FA#: PR#: Program Element: ool62-'7$ 052--7 /6-7 2�� 1 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. Z Tank (2820) ❑ Containers (2821) #of Containers: TA#: COSl645 y . 1 Total Capacity: Z a n gallons Product Type: l o W -3 O (per tank or cumulative for containers by product type) Install Date: �R Tank (2820) ❑ Containers (2821) #of Containers: TA#:Q6-( 0 5 2 Total Capacity: 2 3� (D gallons Product Type: /OVj-3 0 Z) t (per tank or cumulative for containers by product type) Install Date: Pi-Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: 23 C gallons Product Type: (V L') -3o (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: Bri 4 - Product T fit,✓ 30 Total Capacity: 7i 3 o gallons Type: (per tank or cumulative for containers by product type) Install Date: R Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: go gallons Product Type: t5L-j -ZO (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: /Oc>o gallons Total Capacity for Site: p gallons Comments: EHD Inspector: Reviewed Date: Entered Date: -6 By Initial: ey Initial: _ �q *Abov round storage tank means a tank that has the capacity to store 55 gallons or more o "petroleum. v **Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM