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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.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: L�99-e��p/CL S/?l' . Page Z of Facility Address: City: Inspection Date: C:;2-a / 5 /V- /1/lQ�,�r�h�cr,�/i/da FA#: p;, PR M Program Element: 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#: s� 1Product Type: 111201(.1,0�is /�plup Total Capacity: CO v gallons (per tank or cumulative for containers by product type) Install Date: �4 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: Product Type: __M 1j _Z__7 p Y gallons (per tank or cumulative for containers by product type) d/��D Install Date: 7 K Tank (2820) ❑ Containers (2821) #of Containers: TA#: j�p 3 Product Type: /(/J —T— rcr Total Capacity: /00�L/ gallons (per tank or cumulative for containers by product type) a/�p Install Date: O 1Tank (2820) ❑ Containers (2821) #of Containers: TA#: �/��f 4 Total Capacity: (11� Product Type: _222a(I,I�QJ 671 p Y� gallons (per tank or cumulative for containers by product type) Install Date: S�Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: ��,(/S�-j 07./ Total Capacity: LO.� gallons (per tank or cumulative for containers by product type) Install Date: C51L/a o p q Total Capacity this Page:,5/, GI20 gallons Total Capacity for Site: �� 5U3 gallons Comments: EHD Ins ctor: Reviewed Date: Entered DaWX ry By Initial: By initial: /y "A ve and storage tan means a tank that has the capacity to store 55 gallons or more troleum. `"Co ainer means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM