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SAN JOAQUIN COUNTY <br /> — ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> L cr s— h 1 tis Page —/— of <br /> r <br /> Facility Address: cit <br /> / r Y: Inspection Date: <br /> FA#: PR#: Program Element: <br /> 7 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks'and containers** <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: 42�-/ f7/o v <br /> 1 Total Capacity: gj0C7 gallons Product Type: /-1 / 1!:;);/ r-t l,<;.� <br /> (pertank orcumulative forcontamers byproducttype) Install Date: <br /> ❑ Tank (2820) R7Containers (2821) #of Containers: 30 TA#: _Q,,!3-( 7 `7 <br /> 2Product Type: <br /> Total Capacity: � o gallons <br /> (per tank orcumulative for wntainers by protluct type) <br /> 7--7S /la Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: Oso gallons Total Capacity for Site: c�S gallons <br /> Comments: <br /> E <br /> spector: Reviewed <br /> Date: Entered Date: <br /> (�3 By Initial: 0 By Initial: <br /> 'Abo eg and storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> "Cont ner means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />