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' 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: r L- 9/r 6&L C, )All Page -'),—Of Facility Address: City: Inspection Date: C-C9 g/Q.(9 0 Z- ZZ l 7�iI FA#: Program Element: 171' 2 �� 0 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 typ 1:1 Tank (2820) Q"Containers (2821) #of Containers: TA#- 6) 1 �, Product Type: Total Capacity: �� gallons (per tank or cumulative for containers by product type) Install Date: Zr41 ❑ Tank (2820) In Containers (2821) #of Containers: �� TA#: a,��/_037 v2�{ 2c" Product Type: /20 7-2/L 07 L/ Total Capacity: �� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 18 Containers (2821) #of Containers: J TA#: j�6-! 3 Total Capacity: _,j gallons Product Type: A//zs� �r (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (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: 7 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: B *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 091191013 AST SURVEY FORM