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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMF 600 East Main Street, Stockton,CA 95202 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: � j � 2� VA/1 O �✓ L{ �� (� �N i /i��v�✓�`� �A� �l Page L of Facility Address: City: Inspection Date: FA#: PR#: Program Element: '-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. ElTank (2820) l!5l6ntainers (2821) #of Containers: I TA#: ��/;,,7 (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: j< —36 Total Capacity: s gallons Install Date: (per tank r cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: ' T (>250 gallons) (>55 gallons and<250 gallons) ^ 2 Product Type: f,`/J Total Capacity: 200 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) Containers (2821) #of Containers: -7 TA#: (>250 gallons) (>55 gallons and 450 gallons) 3 Product Type: Total Capacity: 2:2 e-C2 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 450 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containsas by product type) Install Date: Total Capacity this Page: / �b gallons Total Capacity for Site: gallons Comments: EHD Inspector. Reviewed Date: Entered Date: Tr 616[ /�--7By Initial: \J-f\j Ok- ( By Initial: —7 6l EHD 28-01 01/16/08