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SAN JOAQUIN COUNTY ` a, & ENVIRONMENTAL HEAL'T'H DEPARTMENT ? 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:wwwsjgov.org/ehd ABOVEGROUND PETROLEUM'STORAGE PROGRAM SURVEY FORM Facility Name- 2-N ,�4' 2 2 Page of Facility Address: City: Inspecti n Date:/ /O I FA#: w PR#: Program Element. Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2t1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulafive container product type. •-Tank (2820) . ❑ Containers (282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1Product Type:. - Total Capacity: J,-6 6 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) t 2 Product Type:: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date:. ❑ Tank(2820) .❑ Containers (2821) #of Containers: TAM (>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) Cl 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) 4 (>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: �f70��` gallon Total Capacity for Site: gallons Comments: IVA;r k-?' /D ?A A116 EHD Inspector: Reviewed pate: Entered Date: By Initial: �•I V By Initial: EHD 2"1 01/16/08