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SAN JOAQUIN COUNTY ' ENVIRONMENTAL HEALTH DEPARTMENT 0 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 N f, /f ? /-1 NES 141U Page/of Facility Address: City: Inspectio Date: 3ont) 4J �J_94 db• 1 77 �yb� EA#: PR#: Program Element: S ) 1e a o3 z � 3 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 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: #: 05)7/a 671 (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: 4 ® 0 gallons (p 2 tank or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers(2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) n [j 2 Product Type: Total Capacity: '1 0 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) 3 Product Type: Total Capacity: 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) 4 Product Type: Total Capacity: 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: _ Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: -T gallons Total Capacity for Site: �d (�' gallons Comments: EHD Inspector: Reviewed Date: ,�/ Entered Date: By initial: > �l•aS-" E By Initial: EHD 28-01 01/16/08