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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: !� - NR y Page of Facility Address• a City: Inspection ate: 11211110 FA#: PR M Program Element: 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. L� Tank (2820) El Containers (2821) #of Containers: TA#: /9,J`3'`�-7 1 Product Type: Total Capacity: h gallons (per tank or cumulative for containers by product type) Install Date: ZTank (2820) ❑ Containers (2821) #of Containers: TA#�: ,h 7 5 g Product Type: � 2 Total Capacity: / a0� gallons (per tank or cumulative for rccontainers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: 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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: ZCt'>'� gallons Total Capacity for Site: 7�j �} gallons Comments: EHD Inspector: Reviewed I Date: Entered Date: �p By Initial: -to. 09 By Initial: `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 09/1 2/08