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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: LF/� 0 S- (� Page / of Facility Address: City: o Inspection D e: / v is o 0 /Ij 0 FA C PR M Program Element: 3 D 31 t93 P,2 - 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. eTank(2820) ❑ Containers (2821) #of Containers: TA#: Fi . 1Product Total Capacity: `S �� gallons Type: ZZ (per tank or cumulative for containers by product type) Install Date: "'Tank (2820) ❑ Containers (2821) #of Containers: TA#:�q�� 2Total Capacity: p y gallons Product Type: '� (per tank or cumulative for containers by product type) Install Date: /Tank(2820) ❑ Containers (2821) #of Containers: TA#: 3Product Total Capacity: 5 (��...�� gallons Type: Jit/ 'q (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: El Tank(2820) [ Containers (2821) 4 1--, Product Type: jK7 P 7-6 it, 0 I Total Capacity: ,j gallons (per tank or cumulative for containers by product type) Install Date: ElTank (2820) Containers (2821) #of Containers: �TA#: IL 5 Total Capacity: � gallons Product Type: 60 b G © � � 9->/2 (per tank or cumulative for containers by product type) Install Date: Total Capacity this Pag D e gallons Total Capacity for Site: gallons Comments: 6•��}'�6 o EHD Inspector: Reviewed Date: By Initial: t t 0 ACV rjp� Entered Date: By Initial: O *Aboveground stefage tank means a tank that has the capacity to store 55 gallons or more of petroleum. l **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08