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SAN JOAQUIN COUNTY a (�2� ' g O <br /> ENVIRONMENTAL HEALTH DEPARTMENT f p <br /> --"600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> a It1A D `1,A1AS AS /JU b-r 14PA60- Page of <br /> Facility Address: City: <br /> 0o pno5t6 � ! g Insp o te: <br /> 5fi <br /> FA#: 6 <br /> g <br /> Program Element: <br /> 2 <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container ro <br /> Tank(2820) ❑ Containers (2821) #of Container TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 1 Product T e: iQ .Q /l <br /> Total Capacity: �0O gallons JA,'� T t� <br /> (per tank or cumulative for containers by product type) Install ate: ` � —p <br /> 12/Tank(2820) l 4ntainers (2821) #of Contain D <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: 0).5 0 gallons <br /> Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers(2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 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: TAM <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 (282 1) #of Containers: TAM <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: 6 2 p gallons Fotal Capacity for Site: Z j> gallons <br /> Comments: <br /> Y <br /> EHD Inspector: Reviewed D t Entered Date: <br /> By Initial: b By Initial a5 5r <br /> EHD 28-01 l/ <br /> 01/16/08 <br />