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r SAN JOAQUIN COUNTY X 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: LC 1 0"1 Page '�= of Facility Address: � / City: Inspection Date• FA#: PR#: Program Element: 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, ❑ Tank (2820) containers (2821) #of Containers: TA#: 1 �, Product Type: T 0' Total Capacity: 1 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (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: j ` !7 gallons Total Capacity for Site: gallons Comments: EHD Inspector: � ✓ Reviewed Date: Entered Date: (" ✓ By Initial: By Initial: /a D *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum`. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08