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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN" o00 East Main Street, Stockton, CA 95202-302, Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name- VOA T 4 CvvN�' GANpr--1 Z-� Page of / Facility Address: City: / 7 2 12 0 9• 6111/ Inspection Date- 4- _T- 0 FA #: PR #: �- a3 Program Element: �. 3 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. ❑ Tank (2820) Q"Containers (2821) #of Containers: �_ TA#: �' 3 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: r Total Capacity: 2 gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) Containers (2821) #of Containers: TA#: 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: Z d gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) C _containers (2821) #of Containers: TA#: 5` 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: Z 94 6 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 1�iontainers (2821) #of Containers: ?i TA#: 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: � /;.' Cr Total Capacity: J/ 6 gallons _.el Install Date: (per tank or cumulative for�iners by product type) '14000Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: 0/0410 gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: L36gallons Total Capacity for Site: Q gallons Comments: EHD Inspector /J Reviewed By Initial: Date: -V4� f . Entered Date: By Initial: /' / q /'�q �] EHD 28-01 01/16/08