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I SAN JOAQUIN COUNTY a. 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: l LA, n2 Page of Facility Address: City: Ins� ti¢ D tey /nt!/ � D: FA#: PR M. Program emen : z Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum X1,320 gallons in tanks*and containers`". Com tete one box for each tank or each cumulative container product type. E� Tank (2820) ❑ Containers (2821) #of Containers: TA#: Z 1 Total Capacity: ( 0 Product Type: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons - (per tank or cumulative for containers by pfoduci type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity, Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: —3 gallons Total Capacity for Site: gallons Comments: P Ali r 1 FHD inspector: Reviewed Date:Q Entered Dat �p, e:8y Initial: l l-l�.v l 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