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SAN JOAQUIN COUNTY �NVIRONMENTAI HEALTH DEPARTMENT F '600 East Main Street;Stockton,CA 95202-3029"L ' Telephone:(209)468=3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM. Facility Name: / G A V 1 S U C.S I N G Page of Fadllty Address: City: Inspectio Date: 39 -2 S �Iw" - 6 Ar i FA#: PR#: 4 Program Element: y. Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2-1320 gallons in tanks and.containers over 55 gallons. Complete one box for each tank or each cumulative container product type. ❑ Tank(2820) lam'Containers (2821) #of Containers: i TAM (>250 gallons) (;�55 gallons and<250 gallons). Product Type: d r Total Capacity: -" 4.0 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: I TA#: (>250 gallons) (>55 gallons and<250 gallons) ;v 2 6 Product Type: or e-,Total Capacity: gallons . . (per tank or cumulative for containers by product type) Install Date: ElTank(2820) l"containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: S 5 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: . 42 z Total Capacity: ZT1 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820), 2820 A'Containers 2821 ( ) ( " ) #of Containers: TA#: (>250 gallons) (>55 gallons and<25b gallons) 5 Product Type: Gf/ T / 4—) Total Capacity: �� gallons s (per tank or cumulative-containers byproduct type) Install Date: ? a. i' Total Capacity this Page: gaUons ETotal Capacity for Site: gallons Comments: I 1 Y EHD Inspector: TReviewed Date: Entered Date: By Initial: Q.'1�� By Initial: „ +1 D I EHD 28-01 L 01/16/08