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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN 600 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 Na L'-12 1v 12 V G Page of Facility Address: City: Inspection Date: LC) c v `T A vir 0 f� k-2- ad FA#: PR#: Progr m Elemen o a o 02-0 1 his' r66 I 2$ 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) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: �i1/4 s' �CC��' Total Capacity: ,_d P gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: l TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: r.S 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) 3 Product Type: nip Total Capacity: /0 D 0 d 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: 5 gallons Total Capacity for Site: ,l® s gallons Comments: C_ T Gvl 7 I,% A7 41 EHD Inspector: Reviewed Date: Entered Date: By Initial: V-o S.�p•p� By Initial: EHD 28-01 01/16/08