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` SAN JOAQUIN COUNTY lb &NVIRONMENTAL HEALTH DEPARTMEN' 0 East Main Street, Stockton,CA 95202-30'. Telephone:(209)468-3420 Fax:(209)468-3433 Web-_��"-gov.org/ehd �lgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: 1 /VC , Page�of Facility Address: I City: Inspect* n Date: • Pvsc l� Gt, N^i7CA S C1WO FA#: VPR#: Program Element: pv© WO/ -5-15-9 2-1 Zg3 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. Er'Tank (2820) ❑ Containers (2821) #of Containers: STA#: (>250 gallons) (>55 gallons and<250 gallons) 1D v o 0 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: D?'*Tank (2820) ❑ Containers (2821) #of Containers: TA#: d ly07 (>250 gallons) (>55 gallons and<250 gallons) _' Y 2 Product Type: y Total Capacity: f&1,9 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (282 1) #of Containers: y TA#: des( 3 (>250 gallons) (>55 gallons and<250 gallons) Type: Product T e• c� Total Capacity: Z-Z-6 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: Z TA#: (,Q (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: igNTl /C/� FIC--2'� Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) V 6ntainers (2821) #of Containers: 'v TA#: — oZ (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: b b gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons FTotal Capacity for Site: 11f(I�) gallons Comments: o �✓ /• n/ o IZ t u VW EHD Inspector: Reviewed Date: Entered Date: � By Initial: �� o• By Initial: EHD 28-01 01/16/08