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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME <br /> 600 East Main Street,Stockton,CA 95202-3 <br /> 1f <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name:� //1/CT`' /S 6-A/I14//,7 ��$'o� Page_�of <br /> Facility Address: a City: Inspect' a Date: <br /> FA#: PR#: Program Element: <br /> oea 3 93d 157/� 703 5r3� <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product Type: PR J' cX77 <br /> Total Capacity: 6B 0A gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Ef"Tank(2820) ❑ Containers (2821) #of Containers: TA#: 196-f <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: v ,,, <br /> Total <br /> Ctank apacity:cumulative <br /> 0 b gallons <br /> yproducttype) Install Date: tc(i <br /> VTank(2820) ❑ Containers (2821) #of Containers: TA#: Q$� <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> Product Type: Llez� , <br /> Total Capacity: ;2 -c gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <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 /> (>250 gallons) (>55 gallons and<250 gallons) <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: / O % 1.-t c- gallons I Total Capacity for Site: 1) gallons <br /> Comments: <br /> A//5k7- To <br /> R l le rD <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> e . G By Initial: 5- By Initial: <br /> / <br /> EHD 28-01 _5 <br /> 01/16/08 <br />