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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMP <br /> 600 East Main Street, Stockton,CA 95202-30�, <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: V461'j <br /> �, t Page of <br /> Facility Address: City: Inspec ion D te: <br /> Zvi ( N Lv Dr, S �v,4o 92� i <br /> FA#: � �� � , I PR#D Prog am Element: <br /> 2 GCS,31 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> Ta 2821) #of Containers: <br /> (>250 gallons) (>55 gallons and�L50 gallons) <br /> 1 Product yp 2iL, Z <br /> Total Ca U V gallons Install Date: F1 rCM 6 <br /> or cumulative for containers by product type) �� <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 3 Product Type: ties-c_, C2 ed nye 1 <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Tank (2820) Kontainers (2821) #of Containers: 2- TA#: 6��? 7adzl <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 I10 Product Type: ,N p�orz, O L 1 S7 - 1-16 011 <br /> Total Capacity: Cj" all _ons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: 69tj/ —2 <br /> (>250 gallons) (>55 gallons and Q50 gallons) <br /> 4 Product Type: &ASb <br /> Total Capacity: 2 V gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank(2820) Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) �- <br /> 5 Product Type: 6 ASD( inrz, M`I Xq� r&44.. <br /> Total Capacity: �6 250 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Q <br /> Total Capacity this Page: , gallons Total Capacity for Site: gallons <br /> Comments: <br /> Irk W511( <br /> EHD Spector. — Reviewed Date: Entered Date: <br /> By Initial: 2J�- Z� 11 By Initial: L �' <br /> EHD 28-01 ` <br /> 01/16/08 <br />