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SAN JOAQUIN COUNTY • ;NVIRONMENTAL HEALTH DEPARTN _J0 East Main Street, Stockton,CA 95202-.,u29 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: 7— N G Page ` of Facility Addre City: Insp tion Dre:56 $ FA#: Q d 1 O PR#: 5-j6 Program El�ent: 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: TA#: (>250 gallons (>55 gallons and<250 gallons) 1 Product T e: Total Capacit gallons (per tank or cumulativ or containers by product type) Install te: ❑ Tank(2820) \(>Kallons ainers (2821) of Containers: TA#: (>250 gallons) and<250 gallons) 2 Product Type: Total Capacity: gallon Install Date: (per tank or cumulative for containers product type) ❑ Tank (2820) ❑ CoA< O 1) #of Containers: TA#: (>250 gallons) (>55 galls)3 Product Type: Total Capacity: ns (per tank or cumulative for containInstall Date: ❑ Tank (282Tcontainers (2821 #of Containers: TA#: (>250 gallons) 50 gallons) 4 Product Type: Total Capacitgallons (per tank or cumulact type) Install Date: ❑ Tank (2 0) ❑ Containers (2821) ##o ontainers: TA#: (>250 gallon (>55 gallons and<250 gallons) 5 Prod t Type: Total C pacity: gallons (per tank or cumulative for containers by product type) Install te: Total Capacity this Page: gallons FTotal Capacity for Site: gallons Comments: Y/G`C �- r 2 A G rgSSgo % � EHD Inspector: /- Reviewed Date: r/ Entered Date: By Initial: Vv'v (P_ 1�-rI 0 By Initial: 4416J EHD 28-01 7�wk 'L 01/16/08