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SAN JOAQUIN COUNTY <br /> WOVIRONMENTAL HEALTH DEPART <br /> 600 East Main Street, Stockton,CA 95202502' <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 /> o IVS r Dv r 0l STT 1q (VPTC 7-R A G y Page l of <br /> Facility Address: City: Inspec on Dat <br /> 2 5 6 d b C-WZ, S , A n/ ' lig <br /> FA#: PR#: Pro ram EI meat: <br /> 0 It -Z <br /> Information <br /> Complete for all sites with cumulative aboveground storage of petroleum >_1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> ❑ Tank(2820) Q"Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>��gallons and<250 gallons) <br /> 1 (�J Product Type: <br /> Total Capacity: 4-4 gallons Cst, 6-y) I <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: T #: fib/0-06 <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: L U 0 gallons of ipYl. 3 0 <br /> (per tank or cumulative for containers by product type) Install Date: <br /> IO/Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: �L�S /�19 � � <br /> Total Capacity: Ll 0 0 gallons 13-39 <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: - #: 9�I � <br /> (>250 gallons) (>55 gallons and<250 gallons) � �� <br /> 4 Product Type: <br /> Total Capacity: / 000 gallons 1p CO-0 L11+ <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ER/Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: 570 0 gallons <br /> Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: gallons Total Capacity for Si*—±±6::D— gallons <br /> Comments: n Vr?I /0-,Vs/,--/ <br /> 7;y0sr %.4 mle-s G o A' Rte" IAI 4,PD1 Tdw o- -rr' 7,1^4-4-1 <br /> EHD Inspector: Reviewed Date: p Entered Date: <br /> By Initial: �,' �� By Initial: "1 <br /> EHD 28-01 <br /> 01/16/08 <br />