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SAN JOAQUIN COUNTY , ENVIRONMENTAL HEALTH DEPARTMI 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: _ V ! f A L.S Page of4-- Facility Address: City: Inspectio Da : FA#: PR#: O Program Element: 000 0b 88 SzZ � �- S3 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: ,T A##: )D,S-11� Z<A 1 (>250 gallons) (>55 gallons and<250 gallons) Product Type: Total Capacity: ,ro a gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: �9�lLe 7 g (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: �� Total Capacity: So O gallons (per tank or cumulative for containers by product type) Install Date: { "rank(2820) Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: ly,gf'rf/ Total Capacity: 2 PO gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) M Containers (2821) #of Containers: TA#: L,26-1 le 7cd 7 (>250 gallons) (>55 gallons and<250 gallons) I 4 Product Type: p [.-- Total Capacity: / -7,15 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank 2820 Ili Containers 2821 ( ) ( ) #of Containers: � �A#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: �,/Y1�/Z d Z-1 Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons I Total Capacity for Site: L✓ gallons Comments: EHD Inspector: Reviewed Date: / Entered Date: By Initial: U-4`1 By Initial: z D EHD 28-01 01/16/08