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i H SAN JOAQUIN COUNTY. b_. WMdWRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax.(209).468-3433 Web:www.sj gov.orglehd ' ABOVEGROUND PETROLEUM STORAGE.PROGRAM SURVEY FORM Facility Name: - �IV�A1 G,9A/ 7 �1/ G/� �� ,�;1L Page of Facility Address: City: Inspec'on D e: OP FA#: PR#: =Program EI-----` �O ZoS �C r Tank/Container Information ' Complete for all sites with cumulative aboveground storage of petroleum i?1320 gallons in tanks and containers over 55 gallons. Com 1 e one box for each tank or each cumulative container ELCduct type. ❑ Tank(2820) E4Containers (2821) #of Containers: .� TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: 1 f gallons Install Da (per tank or cumulative for containers by product type) Date: ❑ Tank (2820) ❑ Containers(2821) #of Containers: ~L TA#- (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: // L) 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) 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: 3 TAM (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: p y' - l� 'r 'gallons . Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ontainers (2821) ##of Containers: TA#: (>250 gallons) (>55 gallons and X250 gallons) 5 `�D Product Type: Total Capacity: gallons (per tank or cumulative for.containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site:// 119 0 gallons Comments: I'3 2-0 4 f!o N S EHD Inspector: Reviewed Date: Entered Date: By Initial: `6,1q• By Initial:I VA Q EHD 28-01 U 01/16/08 ,