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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEl 600 East Main Street,Stockton,CA 95202-30zy Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: �[ r 5 d V A C S S Page of Facility Address: Cit : Inspects, n tep _ 15 �3714 c- J6 P tit-2.Y- A-_V'J_� HROP FA#: PR#: Program ElemeQt: 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. Tank (2820) ❑ Containers (2821) #of Containers: ,TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 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<250 gallons) 2 Product Type: (,(,�GQ, Ol Total Capacity: 2DO gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) PTContainers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) / 3 Product Type:tAD 15D Total Capacity: 65 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ZI Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: � �S� LSD Total Capacity: 5,5 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) 2Tontainers (2821) #of Containers: c)- TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: .�� j 2 Total Capacity: gallons (per tank or cumulative for contamers by product type) Install Date: Total Capacity this Page:_;L1q_,5k!ry gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed e: Entered Date: By Initial: 6 By Initial: EHD 28-01 01/16/08