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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Y A r / l K i L A & V lV Page-,/—of Facility Address: � � � .. A � I�� ity� Ins pec�nlIr `FA#: I , PPRR#: Progrrram Element:(Jy 0 0 '112 ,:r- '5/ 2 37--- 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#: 5-14o%�q (>250 gallons) (>55 gallons and<250 gallons) /J 1 Product Type: f�a,Qf�J Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: R Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 - Product Type: Total Capacity: G-) gallons (per tank or cumulative for containers by product type) Install Date: VTank(2820) ❑ Containers (2821) #of Containers: TA#: ,A�(6-J jr 3 (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: 4C of °a gallons (per tank or cumulative for containers by product type) Install Date: M Tank(2820) L'7 Containers (2821) #of Containers: TA#: � 1Q� (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Gr//4.�%,� bf1� Total Capacity: Zsa 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) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 102-3- 0 gallons Total Capacity for Site: /Q Z gallons Comments: `��J' EHD Inspector: Reviewed Date: �,11 Entered Date: p ✓ By Initial: (.,,J'A By Initial: EHD 28-0 l �+ 01/16/08