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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM 600 East Main Street, Stockton, CA 95202- 29 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: ,FF5, NSA �/ J'T�l �U )/D %� a Page of Facility Address: City: Inspection Date: R �c t�ks/ FA #: 1.4116— PR #: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum > 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: (>250 gallons) (>55 gallons and <250 gallons) 1 Total Capacity: Z .S"O gallons Product Type: ' n• ,TAM ' (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ("Containers (2821) #of Containers: TA#: / [Q 7 2 (>250 gallons) (>55 gallons and X250 gallons) Product Type: Total Capacity: -2. Cl o gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) IR Containers (2821) #of Containers: TAM D51 716 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: P"� Total Capacity: '2-0 b gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) Containers (282 1) #of Containers: TAM & 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: 2-t-0 gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) IF Containers (2821) #of Containers: TAM 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: %J Total Capacity: is -6 gallons . (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: /050 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: By Initial: Entered Da e: By Initial: `Z ( 9 EHD 28-01 01/16/08