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SAN JOAQUIN COUNTY i 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: N%� I']�'% LAATS Page of_� Facility Address: City: Inspect! n D t �7 FA #: G PR #: Program lle ent: 2-9J� 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. #of Containers: TA#: /Tank E:5(2820) ❑ Containers (2821) 1 Total Capacity: 5 b gallons Product Type: Y� S (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: Z2 Tank (2820) ❑Containers (2821) 2J Product Type: -� 0 0 Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: ,.T : UV`I ank (2820) El Containers (2821) 3 � Product Type: i�/r�-F Total Capacity: gallons (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) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: �`��O gallons Comments: EHD Inspector: Reviewed Date: By Initial: rj .1. 0� Entered Date: By Initial: / 0 *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. EHO 28-01 AST SURVEY FORM 09/12/08