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r• SAN JOAQUIN COUNTY 40'ENVIRONMENTAL HEALTH DEPARTMENT X600 East Main Street,Stockton,CA 95202-302$ Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM_STORAGE PROGRAM SURVEY FORM Facility Name: LF W //✓ G Page of I . Facility Address: City: Inspec'on � S S� G1 Af C,01, S ? CG ) 5 D FA#: PR#: Program El' nt 261 5 g g Tank/Coritainer Information Complete for all sites with cumulative aboveground storage of petroleum Z 1320 gallons in tanks and containers over 55 gallons. Com fete one box for each tank or each cumulative container product type. ❑ Tank (2820) Containers (2821) -#of Containers: TA#: (>250 gallons) (>55 gallons and X250 gallons) 1 Product Type: Total Capacity: rc7 gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) VContainers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: S�" gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) Ektontainers (2821) #of Containers: _ TAM (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: y 7o Z zn- L/ _ Total Capacity: r� gallons (per tank or cumulative for containers'by product type) Install Date: _ ❑ Tank'(2820) Ultontainers (2821) #of Containers: 1. #: (>250 gallons) (>55 gallons and<250 gallons) 1 b 4 Product Type: nl C?! Total Capacity: �� gallons ' (per tank or cumulative for containers by product type) Install Date' ❑ Tank 2820 �ntainers 2821 'rte t . { ) ( ) #of Containers: � TA#: (>250 gallons) (>55 gallons and X250 gallons) I 5 Product Type-: a44 lid e.,- Total /Total Capacity: .� gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallonsTotal Capacity for Site: 'Z�75 gallons Comments_ YV l EHD Inspcctor: /J Reviewed Date: / Entered Date- -• ley Initial: �,��0 By Initial: '7 EHD 2"1 v� 0 t/16/08