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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: LT fq 3 r., v1.✓P/ FA C--,M 5 //vr q) Page / of Facility Address: City: Inspecti n Da FA#: PR M Program Element: E-3 -z,g3 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 type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: a$'i- 1�' 1 �j" Product Type: Total Capacity: ��_gallons (per tank or cumulative for containers by product type) Install Date: [-Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2;<3/ii�2 _ 2Total Capacity:p y bC! gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 gallons Product Type: Total Capacity: ;��_g (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: 195S 4 Product Type: /�S '9 Total Capacity: '300 gallons « —7 (per tank or cumulative for containers by product type) Install Date: El Tank (2820) Containers (2821) #of Containers: TA#: 5 Total Capacity: Ill gallons Product Type: �r �' (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector: y _ Reviewed Date: Entered Date: By Initial: ,1.1j-0� By Initial: *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