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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: _ ,% L L- C- Page �' of Facility Address: y Inspecti Date:�- FA#: / / / / _ Program Er t: J/` Tank/Container Information c' " 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: Total Capacity: ��-� gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) PAA-ontainers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: ,Z�J gallons (per tank or cumulative for containers by product type) Install Date: tr/Tank (2820) 0 Containers (2821) #of Containers: TA#: 3 Total Capacity: 35C gallons Product Type: -/,, (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: Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 173 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: y, By Initial: By Initial: P *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 09/12/06 AST SURVEY FORM