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,i _ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT =y 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: T LIMm� A Page / of J Z o f= Gv�S. Facility Address: City: Inspec ion De; W�, /a/7,910'g FA#: PR#: Progral DD l 3 a PI-6-Z it ' Tank/Container information Complete for all sites with cumulative aboveground storage of petroleum 11,320 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::0-4Onn Q ) Total Capacity: �� gallons (per tank or cumulative for containers by product type) Install Date: ' El Tank (2820) ElContainers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: _ (per tank or cumulative for containers byproduct type) Install Date: 3 ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: I (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for site: Z J b gallons Comments: o ,� s 7)J0 A" EHD Inspector: ✓ Reviewed Date: / Entered Date: By Initial: U By Initial: I *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 09/12108