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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: Lj,, 6e_ & Qi % _ _ _J. __.., .y —"„ a La„n i„a.... oLo- i „a, 111e cdpauay to store 55 gallons or more Page _� of -2-- Facility Address: 6�i20 City: Inspection Date: a of /� ue_,., FA #: PR #: Program Element: 0-.5-3) 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. ,27 Tank (2820) ❑ Containers (2821) #of Containers: TA#: O S/ by"3-7 1Product Total Capacity: f 00,0 gallons Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2820) #of Containers: TA#: 2 1 V Total Capacity: Y10 gallons Product Type: %—F (per tank or cumulative for containers by product type) Install Date: YK Tank (2820) ❑ Containers (28�2/�) #of Containers: TA#: 3 ' LC' 1 Total Capacity: f %t52 gallons Product Type: Sc.J --3J •� �{�. �� / (per tank or cumulative for containers by product type) Install Date: ,Ik-Tank (2820) ❑ Containers (28d #of Containers: TA#: 4 Total Capacity: %%(� ' Z gallons p tY� Product Type: O(�-3� .•-o-�.- ai� (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: OSl6 4 41- 1 °' 5 Total Capacity: , ) 2—,.:> gallons Product Type: 5�"✓ (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site:gallons Comments: U _ rj NJ EHD In a Reviewed By Initial: Date:g-�Q �D' Entered Date: By Initial: &/41/j/�), vAnrni end ctnrnnn f-14 .,, ., 4. i. «., �__ . f petroleum. ” / ' **Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM