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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: _ L-6 i J d A N Page of Facility Address: City: Inspectiof Dat SI Ant ALI- � 9771 71 FA#: PR#: Program Elemen. 3 6 ©�a�'gga `219 3o 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 05TR 1 Product Type: Total Capacity: C�� gallons (per tank or cumulative for co tainers by product type) Install Date: (Tank (2820) El Containers (2821) #of Containers: TA#: 05 �$�f�� 2Product Type: Total Capacity: ,5-r) P gallons (per tank or cumulative for containers by product type) Install Date: 2/Tank (2820) El Containers (2821) #of Containers: ,TA#: L2Ei I S�Ictp 3 Total Capacity:acit : r-o 6 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#*� 4 Product Type: _ Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: / 500 G gallons Total Capacity for Site: /J'a 0 gallons Comments: EHD Inspector: Reviewed Date: Entered �� Date: By Initial: ,n �l �.'L�' (9� By Initial: 5-1A *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