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:rte "a J.A SAN JOAQUIN COUNTY 14• 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 STORAGEiPROGRAM SURVEY FORM Facility Name: CCVWSE nIG Page of Facility Address: City: Ins pec I at 2 515 o S• 1, �, a A D r>� / M FA#: PR#: Programf 27 92 - :off Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum x1,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TAS 1 Total Capacity: 3o7O gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) qk6`ontainers (2821) *of Containers: TA#: 2Product Type: D Total Capacity: f"� gallons - ---- (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ElContainers (2821) #of Containers: TA#: 3 'Product Type: Total Capacity: galleons (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#: t5 Total Capacity: gallons Product Type: i (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: , gallons Total Capacity for Site:1 5!�& gallons Comments: WSF a �0 o r � Loll :. EHD Inspector: ReviewedDate: Entered Date: By Initial: f�p.(�. By Initial: B *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