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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.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: NICL F. NoiZj5 /R Page —jL\-6f Facility Address: city: Ins�ti �D7tq!e 6 NNAPJ r FA#: PR C Program Element, -3 LI-61a`� 8 5 2 $ Ly�- 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. Q" Tank (2820) ElContainers (2821) #of Containers: TA#: 1 Product Type: 2, P/ou Total Capacity: gallons �(pe�tankorcumulativefor nlainersbyprotlucttype) Install Date: f' Tank (2820) ElContainers (2821) #of Containers: TA#: 2 Product Type: �Y�1 Total Capacity: ?2p j gallons (per tank or cumulative for containers by product type) Install 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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: D gallons Total Capacity for Site: gallons Comments: Z lojwlj EHD Inspector Reviewed Date: Entered Date: / v By Initial: l,,,a.-p� By Initial: ) p '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