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1 o 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: I- LA Die/ o UPE I-AAIM5 Page of Facility Address: � City: Inspectign Dat�/ FA#: PR M Program Element: l 7 5 � D 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. ank (2820) El Containers (2821) #of Containers: - TA#: _8,�/ 1 Product Type: .Z4201� Total Capacity: gallons (per tank or cumulative for cbfitainers by product type) Install Date: �nk (2820) ❑ Containers (2821) #of Containers: TA#: d 6-113 117 2Total Capacity:p y gallons Product Type: � L)�2s�Q� (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: d�5-1 1 15? 3 Product Type: Ylq Total Capacity: Q�'�'� gallons (per tank or cumulative for containers by product type) Install Date: ICZ/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: / 0--(qgallons allons Product Type: N -7 (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: W _ 5Product Type: 111A r �r Total Capacity: � G� gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: C7 0 gallonsTotal Capacity for Site: gallons Comments: r EHD Inspector: Reviewed Date: Entered Date: r� By Initial: $,'�-�.(� By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more 6f petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08