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SAN JOAQUIN COUNTY <br />r ENVIRONMENTAL HEALTH DEPARTMEN <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />Facility Na e: <br />'% 6 <br />— V E G )CA e/ �' <br />Page of <br />Facility Addres : <br />City: <br />Inspection D te: <br />/ 03 <br />Z <br />p nl <br />FA #: <br />PR <br />N 6 ag g <br />Program Element: <br />2 9✓X-- <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum >_ 1320 gallons in tanks and containers over 55 gallons. <br />Complete one box for each tank or each cumulative container product type. <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: QS� 7� <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />n / <br />Total Capacity: JCS0 gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: 9 &-9 <br />qj <br />/ <br />Total Capacity: / U V D Q gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TAM <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) ❑ Containers (2821) <br />#of Containers: TA#: <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Total Capacity this Page: 2-00 O C)d <br />gallons <br />Total Capacity for Site: z O " d gallons <br />Comments: <br />EHD Inspector: ` V <br />Reviewed Date: <br />By Initial: jo-�' q� <br />Entered Date: <br />By Initial: z �/dFo/ <br />EHD 28-01 <br />01/16/08 <br />