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SAN JOAQUIN COUNTY ?NVIRONMENTAL HEALTH DEPARTMET' 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: nn / C, HHAIJ N �' O�✓C. ' Page l of Facility Address: City: Inspectio e: ��2� odd,- �p7 �y FA#: PR#: Program ement: 1 z- g - � Tank/Container Information Complete fo all sites with cumulative aboveground storage of petroleum >_1320 gallons in tanks and containers over 55 gallons. f Complete one box for each tank or each cumulative container product type. P Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 d Product Type: 17,E Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: N,5-14, 1 / (>250 gallons) (>55 gallons and<250 gallons) 2 � Product Type: Total Capacity: 3 ° gallons (per tank or cumulative for containers by product type) Install Date: 12 Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: ZyO&STS o! t1 Total Capacity: .j o D gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) Imo"Containers (2821) #of Containers: TA#: !y S/(P / / , (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: � � L- Total Capacity: 11O gallons (per tank or cumulative for containers by product type) Install Date: Tank(2820) 0 Containers (2821) __#sPC6n`tainers: TA#: ��/Le (/ (>250 gallons) (>55 gallons and<25 _� 5 Product Type: Total C / O g (��,�,�„� per tar- or cumulative for containers by product type) Install Da e: 1 20 O Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: IAJ- off /05A.M /7-E S S-- t7-C' sp L-A T ztts' EHD Inspector: Reviewed /� te: Entered Date: / v By Initial: ( � � By Initial: nQ EHD 28-01 01/16/08