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SAN JOAQUIN COUNTY �ENYIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-302 Telephone:(209)468-3420 Fox:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: C N A.2 / Page of Facility Address: /' City: Insp do Date: FA#: PR#: Program Elerrtept: 995 2 s3 ,- Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Com tete one box for each tank or each cumulative container product ❑ Tank(2820) Containers(2821) #of Containers: TA#: DSI (>250 gallons) (>55 gallons and<250 gallons) l Product Type: Total Capacity: �gallons (per tank or cumulative for containers by product type) Mall Date: L/ ❑ Tank(2820) MlContainers (2821) #of Containers: ,L_ TAM (>250 gallons) (>55 gallons and 250 gallons) 2 Product Type: 4W.4 S?e Total Capacity: l 2 t?2 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) ��S— n� 3 ,JJJf Total Capacity: 2, 3 � Product Type:gallons Install Date: (per tank or cumcontainers ulative for by product type) ❑ Tank(2820) Mo ontainers (2821) #of Containers: TA#: 0,Sl7,348 (>250 gallons) (>55 gallons and<250 gallons) 4 7' Product Type: �'Y�0 Total Capacity: / 7-0 gallons Dt,� (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) (Containers (2821) #of Containers: TAM 19z�J 73{9 (>250 gallons) (>55 gallons and Q50 gallons) 5 Product Type: Total Capacity: co D gallons Install Date: (per tank or cumulative for containers by product type) - Total Capacity this Page: L? gallons Total Capacity for 5itt -Aw 0 gallons Comments DID Inspector: Reviewed Date: d Entered Da C. By Initial od By Initial: EHD2"I 01/16/08