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SAN aJOAQUIN 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 I I 66— f N C Page of !� Facility Address: City: Inspection Date: , FA#: PR#: Program Eluent: 17'r o 0312- 37- Tank/Container 7,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. Rr Tank (2820) El Containers (2821) #of Containers: TA#: �,5/ 1 Product Type: L412 /L�� Total Capacity: /0 0. 0 d gallons (per tank or cumulative for containers by product type) Install Date: L d/Tank (2820) ❑ Containers (2821) #of Containers: TA#. 0 2 � Product Type: G Total Capacity: l e2 0 gallons (per tank or cumulative for containers by product type) Install Date: Q'Tank (2820) ❑ Containers (2821) #of Containers: TA#: Dom/ `7� 3 .-a Total Capacity: "'U gallons Product Type: (1z,4 -5 t� �--, (per tank or cumulative for containers by product type) Install Date: 1-11 #of Containers: TA#: t26-1`7 3' 1 R'Tank (2820) ❑ Containers (2821) 4 Total Capacity: _ ) d Product Type: y" ��rC� &Li�i rel V p y: gallons (per tank or cumulative for containers by product type) Install Date: ID/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: 7 S-C7 gallonsl Total Capacity for Site: /f gallons Comments: EHD Inspector: J Reviewed Date: Entered Date By Initial: b, By Initial: 11 `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