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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN <br />600 East Main Street, Stockton, CA 95202-3029 <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 />rIZARVITE a o A % v D l !9/11 <br />&e` <br />Page _� of <br />Facility Address: <br />o s�� s• l �� <br />rty: <br />L <br />Inspect' nte- <br />s o d <br />FA #: <br />C) G U 5 S- !1 <br />PR #: <br />r� 01- <br />ProgramElement: <br />'L Y3 Y <br />Tank/Container 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) ❑ Containers (2821) <br />#of Containers: <br />TA#: <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: f�,J <br />, n <br />Total Capacity: 2 O b V D gallons <br />Install Date: <br />(per ror cumulative for containers by product type) <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TAM <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: � 2� <br />e.�1L <br />Total Capacity: Z0 a G 0 gallons <br />Install Date: <br />d <br />(per tank or cumulative for containers by product type) <br />Ua/Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TAM 061 <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: ,I, <br />o T-0/2- p <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TA#: 6611e I c30 <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: /5� <br />Total Capacity: / G -V - U gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />IP/Tank (2820) ❑ Containers (2821) <br />#of Containers: <br />TAM llO rl c� <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: o gallons <br />(per tank or cumulative for containers by product type) <br />Install Date: <br />Total Capacity this Page: L 6S— <br />gallons <br />Total Capacity for Site: gallons <br />Comments: <br />G �✓ %I G F <br />EHD Inspector:Reviewed <br />�� D <br />By Initial: I <br />ed Date: <br />� <br />iitial: <br />L <br />( <br />EHD 28-01 <br />01/16/08 <br />