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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: (� N I v � SLY �� C� i (_0 4 1)Page d l of Facility Address: City:Inspe . � � • �� {�� tion Date: 2 2 510 FA #: 2 PR #: 591�lyv Program Element: 2a Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. ❑ Tank (2820) Containers (2821) #of Containers: TA#: �.h I '7q 1 Total Ca acit 3 3 y Product T p y: gallons — (per tank or cumulative for containers by prod ypcJ Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 06'1 `7 3 2Product {tZ Total Capacity: 2. � j> gallons Type: 1.e�P-L F-Va-L (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: (5 ,f / %!' q `f 3 Total Capacity: l (� gallons Product Type: (�) %QST-L� LU�22� ��L (per tank or cumulative for containers by product type) Install Date: i Tank (2820) ❑ Containers (2821) #of Containers: TA #-. 4Product Total Capacity: 2 a L� gallons Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: l� l 5 Go - Product-TW� Total Capacity: 00 gallons (per tank or cumulative for contamers by product type) Install Date: Total Capacity this Page: 3 C -f —7 gallons Total Capacity for Site: �'70 gallons Comments: C L r—CV n S� D 3 0(_ L PJ 0- C4 go 4, h EHD Inspector: UU� 4A— Reviewed Date: By Initial: FEntered Date: 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 09/12/08