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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN�.s 600 East Main Street,Stockton,CA 95202-3029 Telephone.(209)468-3420 Fax.(209)468-3433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: L/ TND GI-r ' &f ` LG 7 CaM 0VN!! Page of Facility Address: City: Inspectio Due: /S F ? ST LA o zrf o � FA#: PR k: r Program Ele nt: a1 0 16 ol,125 ^$ z. 8 0 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product Tank (2820) ❑ Containers(2821) #of Containers: Til#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: Z s 0 gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers(282 1) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) 0 Containers (282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) -- 4 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by pmdwt type) - ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for conta�uct type) Total Capacity this Page: 2..,Sf7 gallons Total Capacity for Site: Z gallons Comments: D e //='Gr �e i OY sa.l � L �1 EHD Inspector: Reviewed Date: Entered Date: 6y Initial: .�b. By Initial: /- D EHD 28-01 01/16/08