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SAN JOAQUIN COUNTY <br />3NVIRONMENTAL HEALTH DEPARTMEN <br />A East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />Facility Name: <br />Nal 0 r /1 C y " OJ(9yID SE2 VICE CrNrr)k <br />Page ` of 7_ <br />Facility Address:City: <br />s�0 s 0o T 2l e 9�3 �� <br />Inspection Date: <br />FA #: • _ <br />PR #: <br />Program Element: <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum 2t1320 gallons in tanks-4 <br />anksnd containers over 55 gallons. <br />Complete one box for each tank or each cumulative container roduct <br />Tank (2820) ❑ Containers (2821) #of Containers: TA#:e2 <br />1 <br />(>250 gallons) (>55 gallons and <250'gallons) <br />Q Product Type: <br />Total Capacity: Ions <br />Install Date: <br />(per tank or cumulative for contain uct type) <br />❑ Tank (2820) Containers (2821) #of Containers: y TAM 06-119 <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: y %�/� L CC,.,Q <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) Le Containers (2821) #of Containers: TAM /i5 7D7,Z <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: �\De <br />% <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product type) Install Date: <br />❑ Tank (2820) Q Containers (2821) #of Containers: TA#: of / 70 7 <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Total Capacity: t7 Product Type: D Sl Z --( <br />gallons" . <br />Install Date: <br />(per or cumulative for containers by product type) <br />Tank (2820) ❑ Containers (2821) #of Containers: TAM _7 77 <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: D 00,0 gallons <br />Install Date: <br />_ <br />(per tank or cumulative for c tainers by prod4cttyl5e) ., <br />Total Capacity this Page:-allons <br />Total Capacity for Site: - ' gallons <br />Comments: <br />EHD Inspector: c/ <br />Reviewed Date:�/ <br />By Initial: <br />Entered Date: <br />By Initial: <br />tol D 6 <br />EHD 28-01 <br />01/16/08 <br />