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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHDEPARTMEN*....4 ` 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209)468-3420 Fax. (209)468-3433 Web:www.sigov.org/chd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name V A S / LVA Page f of Facility Address: C't � Inspectio Dat O v' FA#: PR#: ' Program Elem en- IN- 0 a ZS Tank/Container InforAiation Complete for all sites with cumulative aboveground storage of petroleum z 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: (>250 gallons) (>55 gallons and<250 gallons) I Product Type: t n A 11 Total Capacity: (0 0 gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: 2 (>250 2 gallons) (>55 gallons and 50 gallons) i Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and 250 gallons) 3 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA": (>250 gallons) (>55 gallons and 250 gallons) 4 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product eypc) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) g Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: 0 06 gallons Comments: EHD Inspector: Reviewed Date: Entered Da : f' By Initial: a.��_(� By Initial: 0"qL&Lpg EHD 2"1 01/16/08