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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME 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: LV� A U a Page of 3 Facility Address: Ci Inspecd w 2 T75 FA#: PR#: i D V 1 O 07� 7Prog� Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: 10 U G o gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Total Capacity: allons Product Type: A 9 ��—g (per tank or cumulative for containers byproduct type) Install Date: IR/Tank(2820) ❑ Containers(2821) #of Containers: TA#: (� (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: n�% [i Total Capacity: /n 0 O gallons (per tank or cumulative for cotainers by product type) Install Date: El Tank (2820) IR/containers (2821) #of Containers: . TA#: 4 X250 gallons) (>55 gallons and<50 gallons) Product Product Type: 6;.6,0/7, Total Capacity: 7..Z.o gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) Containers (2821) #of Containers: _ TA#: B (>250 gallons) (>55 gallons and<250 gallons) 5Product Type: i L Total Capacity: 3 3o gallons P (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: /,Z gallons Total Capacity for Site: �� gallons Comments: EHD inspector: a Reviewed / ` By Initial: �, N/p Date: /b^u p Entered Date: By Initial: EHD 28-01 Gc 01/16/08