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I- L SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEIN 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: L411 L J3 V/? L Li�S C-6 Page _� of Facility Address: City: % S. kL -r GOTT Inspectiyn Date: -r/l FA #: PR #: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum > 1320 gallons in tanks and containers over 55 gallons. Com Tete one box for each tank or each cumulative container product type. ElTank (2820) Containers (2821) #of Containers: TA#: (9h //�t6 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: 0/ 1, Total Capacity: %r gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) P Containers (2821) #of Containers' % TA#: kA fr 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: i gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) Containers (2821) #of Contain rs: TA#:/ �p 3 (>250 gallons) (>55 gallons and <250 gallons) Product Typ D %►/ o Total Capacity: / 2-Z) gallons Install Date (per tank or cumulative for containers by product type) ❑ Tank (2820) Containers (2821) #of Containers: / TA#: 4 (>250 gallons) (>55 gallons and <250 gallons) !' 1 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) containers (2821) #of Containers: \� TA#: 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: / gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: t f gallons Total Capacity for Site: t (� gallons Comments: EHD Inspector: (V r Reviewed I Dat � : 0� By Initial: N lf'�� ' Entered Date: By Initial:�z �, EHD 28-01 01/16/08