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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME 600 East Main Street, Stockton,CA 95202-3U/-y Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: L a G X /i f, SS Page of Facility Address: City: Inspection Date: C(9 49,6 SS - 1� r/� itii - -L'10 FA#: PR#: ✓ Program EI men ao 032 g SS / 2_g3 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >1320 gallons in tanks and containers over 55 gallons. _/ Complete one box for each tank or each cumulative container product type. E "1 ank (2820) ❑ Containers (2821) #of Containers: TA#: &7& (>250 gallons) (>55 gallons and<250 gallons) 4 1 Product Type: �.L��e Total Capacity: � � � ° d gallons -� (per tank or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TAM '51 (>250 gallons) (>55 gallons and<250 gallons) 2 � Product Type: Total Capacity: 5; gallons (per tank or cumulative for containers by product type) Install Date: P/Tank (2820) ❑ Containers (2821) #of Containers: TA# d (>250 gallons) (>55 gallons and<250 gallons) 3 � Product Type: Total Capacity: 'r.� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ontainers (282 1) #of Containers: �_ TAM (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: S'3 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons TTotal Capacity for Site: gallons Comments: /►� ►,✓ Sa��l To /�✓ U 7!�/ L o r �M6h� EHD Inspector: Reviewed Date: Entered Date: By Initial: IAJ 5d0t By Initial: b EHD 28-01 V 01/16/08