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ISAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />i00 East Main Street, Stockton, CA 95202-31 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />i <br />ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />Facility Nam (` <br />NnWC- r - o ;RATI 61v <br />1 <br />Page of <br />P0 1\1 5 D MAI IVT 15 <br />Facility Address: City: <br />o f N. /Ng1r0tv <br />Inspecti nn DDate: d <br />g <br />FA #: <br />oo/ W3 <br />PR #: <br />D5aga04? <br />Program Elemen : <br />2�3y <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum Z 1320 gallons in tanks and containers over 55 gallons. <br />Complete one box for each tank or each cumulative container product type. <br />Tank (2820) ❑ Containers (2821) #of Containers: TA#: � q' <br />1 <br />(>250 gallons) (>55 gallons and <250 gallons) �� S <br />Product Type: <br />10_ <br />Total Capacity: G o gallons <br />Install Date: <br />(per tank r cumulative for containers by product type) <br />Tank (2820) ❑Containers (2821) #of Containers: TA <br />2 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: /6 (7 O a gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) 4,Containers (2821) #of Containers: Z TA#:�SJ 9'�e ' 9 <br />3 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: / 1 C gallons <br />Install Date' <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />4 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />5 <br />(>250 gallons) (>55 gallons and <250 gallons) <br />Product Type: <br />Total Capacity: gallons <br />Install Date: <br />(per tank or cumulative for containers by product type) <br />Total Capacity this Page: Q Q gallons <br />Total Capacity for Site: 0 6 gallons <br />Comments: NC. yl/ , 1Q OR IV <br />2s �9�� Zoe O <br />EHD Inspector: <br />f <br />Reviewed Date: <br />By Initial: W' '1 p� <br />Entered Date: <br />By Initial: % $ 11 <br />EHD 28-01 <br />01/16/08 <br />