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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN A0 East Main Street,Stockton,CA 95202-302> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: l r' ✓ C_ f VAI r S Page / of Facility Address: / City: Insp�ecytio ;)� yZLk 22 �/• � �ilT Lr n// S P'� / / FA#: PR#: Program Element: oC)/C) C(')I �� I z 53V, 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#: (>250 gallons) (>55 gallons and<250 gallons) O 1 Product Type: Total Capacity: / 2- 0 0 D gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Lh'Containers (2821) #of Containers: v TA#: r,5) 70`�'S (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: G j Total Capacity: // O gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) containers (2821) #of Containers: 1 TA#: 1Q,�`70 (>250 gallons) (>55 gallons and<250 gallons) / 3 Product Type: Total Capacity:t 5 S gallons (per tank or cumulative for containers by product type) Install Date: ElTank (2820) Containers (282 1) #of Containers: STA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: 'ZZ 2 O 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: 016- Total Capacity: S L719 gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Z gallons FTotal Capacity for Site: 3. J gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: vj"j -1 •Ll-lo By Initial: Q 'Ilk- EHD 28-01 V 01/16/08