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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 Facilit N y ame. CVI vy-no Page of Facility Address: City: 28 8 K a sso n �d -vra Inspection Date: 28'' / O FA #: PR #: 382 01_510581_78 Program Element: 2Sf>4 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. #of Containers: TA#: O0) (a 1 414 J Tank (2820) ❑Containers (2821) 1 Total Capacity: I, 401) 8'-3✓2 gallons Product Type: 'Suolnx P, LID gas (per tank or cumulative for containers by product type) Install Date: D Tank (2820) ❑ Containers (2821) #of Containers: TA#: 0` ( Lol45 2J Product Type: Total Capacity: g22 � 2�D gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: O� J Col ` (,o 3 Product Type: _7 (" m 1' X Total Capacity: -4�j, I (g gallons (per tank or cumulative for containers by product type) Install Date: © Tank (2820) ❑ ContainIrs (2821) #of Containers: TA#: O'E-) 16-9 141 4 Total Capacity: r'� , 000 Product Type: gallons (per tank or cumulative for containers by product type) Install Date: 21/Tank(2820) ❑ Containers (2821) #of Containers: TA#: 05 5V Product Type: � h I-Md-tld Total Capacity: 2, q9) (.0'5Z gallons �� (j q S (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page:,�3a� gallons Total Capacity for Site: -72 gallons Comments: EH a r: _ Reviewed Date: By Initial: (�.��,t0 Entered By Initial: Date: z .,�u/ y1uunu storage iarrK means a tanK tnat has the capacity to store 55 gallons or more of petroleum. ntainer means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM