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SAN JOAQUIN COUNTY N b T G i✓ �/✓l��s NTbR y ENVIRONMENTAL HEALTH DEPARTMEN' 600 East Main Street, Stockton,CA 95202-3027 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: • L C r G�!�l �� Page f of Facility Address: city. Inspect' n D e: LZX4)1 'rLoi r a FA#: PR#: Program ement: z Sal Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. Eg/Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) Q 1 Product Type: ��.� Total Capacity: �'�o8 gallons (per tank or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: �,�, T�A#: QJ' f lenfl 2 Product Type: (>250 gallons) (>55 gallons and<250 gallons) lllz� �l/ Total Capacity: Ae gallons (per tank or cumulative for containers by product type) Install Date: ;7Tank(2820) ❑ Containers (2821) #of Containers: -TA#: /�,s;J[f p q a'-- (>250 gallons) (>55 gallons and<250 gallons) h 3 Product Type: Total Capacity: 7 6W& gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 3 p 6 0 gallons TTotal Capacity for Site: -3000 gallons Comments: &P-r 0A1 2�./j'D� EHD Inspector: Reviewed Date: Entered Dater I ZL 1 By Initial: By Initial: k( EHD 28-01 01/16/08