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SAN JOAQUIN COUNTY ,,,o <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax. (209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> LBA 11A P A lvc, 14Page _� of <br /> Facility Address: city: Inspec Ion Da <br /> /viv �o <br /> FA p: PR#: Program Element: <br /> 2 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks' and containers". <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumuiaave for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: 3 gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: <br /> 'Abovegroun storage tank means a tank that has the capacity to store 55 gallons or more 6f petroleum. <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 09112/08 <br />