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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: N U 1 A Page of Facility Address: City: Inspec 'on te• - *i _?. TRF_1)W1q 1 �/ s 6 FA#: PR#: Program 151 ent: 86I C) z8 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container product type: 9 .Tank (2820) ❑ Containers (2821) #of Containers: TA#: Y 1 Product Type: =:k '�T Total Capacity: gallons7. (per tank or cumulative for containers by product type) Install Date: ! Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: D� gallons Product Type: (per tank or cumulative for containers by product type) Instal! Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Instal! Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: lr TA#: 8 Total Capacity: gallons _ Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: g gallons Comments: �r F C psr1y EHD tnspector: Reviewed Date: Ente4Yred Date: By Initial: tt_61. By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08