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k M ti, SAN JOAQUIN COUNTY , ENVIRONMENTAL HEALTH DEPARTMENTT 600 East Main Street, Stockton, CA 95202- 3029 Telephone: _ p e: (209)468 3420 Fax. (209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND'PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Im I v L Facility Address: Page o f �� l 1 I ! ��. City: Inspection Date: FA.#: PIR#: / I� Program Element: -i 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 roduct type. LTJ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: gallons Product Type: (per tank or cumulative for con iners by product type) �— Install Date: Tank (2820) ❑ Containers (2821) #of Containers: . TA#. 2Product T e: ` Total Capacity: �"� gallons yp (per tank or cumulative for containers by product typc) Install Date: VTank (2820) ❑ Containers'(2821) ' :#af Containers: TA#: 3 ;Total Capacity: agallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) f ontainers (282'!) #of Containers: TA#. 4 Product Type: Total Capacity: ` gallons Yp ' (per tank or cumulative for containers by product 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: Q gallons Total Capacity for Site: gallons Comments: LHOnsp Re�Initial: Date: Entered Date: By !j�Ly•t 4 By Initial: ` C Ov rou storage tank means a_tank that has the capacity to store 55 gallons or more of petroleu "Cont ' r means a storage device designed to be moved when full. EHD 28-01 09112108 AST SURVEY FORM