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l `I 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: L-- 1 G N Page - of Facility Address: City: Inspecti Date: FA#: PR#: 6f Program Element: 196-oz-7 M; 1z �� Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum�4 20 gallons in tanks*and containers**. Complete one box for each tank or each cumulative co tainer product type. ❑ Tank (2820) Containers (2821) #of Containers: TA#: 1 Total Capacity: S b d gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Xt/' 13'Tank (2820) ❑ Containers (2821) #of Containers: TA#: V�J�S'o2 c3 62 2Total Capacityp y gallons Product Type: P//- (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ #of Containers: TA#:Containers (2821) 3Product Type: C�S d - � Total Capacity: ��1 gallons (per tank or cumulative for containers by product type) Install Date: �I Tank (2820) ElContainers (2821) #of Containers: TA#: 4 /i✓/ris' Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) © Containers (2821) #of Containers: y� TA#: g a 5 Product Type: Total Capacity: !�0 gallons (per tank or cumulative for containers by product type) Install Date: Y/a Total Capacity this Page: '3 00 gallons Total Capacity for Site: S gallons Comments: EHD Inspector: ,/ Reviewed Date: Entered Date: By Initial: V"� �i,"l,'p, By Initial: g O *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