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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <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 Name: <br /> VLM ny� Q Page_� of <br /> Facility Address: city: Inspec on D to: <br /> 2 2 215 NQ rp�vi ous( 23W85 �C�c.f o v? �l -3c) I LI <br /> FA#' PR#: Program Element: <br /> S iR 0e?28-3 r5 X840 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers**. <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: O'j <br /> 1 Total Capacity: LOCI gallons Product Type: mntor tr // <br /> (per tank or cumulative for containers by product type) Inst <br /> Tank (2820) ❑ Containers (2E _ TAM OGI.-7 70 O <br /> 2 Total Capacity: (�)O (D galk <br /> (per tank or cumulative for containers by product type) YI I <br /> X Tank (2820) ❑ Containers (28: _ TA#: <br /> 3 Total Capacity: 22—CDgallons Product Type: mof-or 01 <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) containers (2821) #of Containers: t TA#: 0 —7 Vqg <br /> 4 Total Capacity: r0 CJ gallons Product Type: VII/�{�((I L(it' n1 <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) b(Containers (2821) #of Containers: TAM <br /> 5 Total Capacity: ( LP e5 gallons Product Type: ('1'l0ft>— O I I <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: gallons Total Capacity for Site: 14-05 gallons <br /> Comments: <br /> C-hhy # I -f;1-2 . #71 loose o <br /> Y �} M LL � qto <br /> l <br /> T' Oddy-iS;9 <br /> )J 1 <br /> EHD I actor: — Reviewed ate: Entered Date: <br /> By Initial: By Initial: <br /> *Abo egro d storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> **Co . er means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />