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SAN JOAQUIN COUNTY IRONMENTAL HEALTH DEPARTMENT East Main Street, Stockton,CA 95202-30 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: A z PIiVA�, �., Page / of Facility Address: Cit ins cc on Dale ?�®m �� Ari STIP z �F FA#: O oO 9 z 9 1 PR:: / Pr gram Element: KG 80 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 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#: 2kaflonsl, (>55 gallons and<250 gallons) Product Type: TCa city: gallok or c live for containers by product Install Date: ❑ Tank(2820%_) 5,5Cg tainers 2821) #of Containers: TA#: (>250 gallons) ns and 50 gallons) Z Product Type: Total Capacitygallons (per tank or cumulas product type) InstallDate: ❑ Tank(2820) ❑ \' ers 821) #of Containers: TA#: (>250 gallons) (>55 allallons) 3 Product Type: Total Capacity: llons (per tank or cumulative f containeype) Install Date: ❑ Tank(2820 ❑ Containers (2 1) #of Containers: TA#: (>250 gallons) (>55 gallons and Q50 gall ) 4 Product Type: Total Capa ty: gallons (per tank or c ulabve for containers by product type) Install Date: ❑ T (2820) ❑ Containers (2821) #of Containers: TA#: (>250 Ilons) (>55 gallons and<250 gallons) 5 oduct Type: Total Capacity: gallons (per tank or cumulative for containers by product type) all Date: Total Capacity this Page: gallons I Total Capacity for Site: gallons Comments: �Aa/KS ACi$ �6 CAI EHD Inspector: Reviewed Date: J Entered Date: By Initial: tjvo By Initial: oS - EHD 28-01 01/16/08