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� - <br /> ►. �.-' SAN.1ROAQUIN 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 /> /!`-E--A 6ROS Page of t <br /> Facility Address: City: Inspect o <br /> FA#: y PR#: r; Program Elem n <br /> 6LL b a J �8 <br /> TanldContainer Information <br /> Complete for all sites with cumulative aboveground storage of petroleum x1,320 gallons in tanks*and containers**. <br /> � <br /> Complete one box for each tank or each cumulative container product e. <br /> I3/Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> yP . <br /> Total Cap,. 3 �=- gallons Product T e. <br /> {per tank or cumulative for containers by product type) Install Date; <br /> ,3/Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Total Capacity: d-Dgallons Product Type: - 7- .S,_, <br /> (per tank or cumulative for containers by product type) Install Date: } <br /> ❑ Tank (2820) ❑ Containers (2829) #of Containers: TA#: <br /> 3 Product Type: <br /> _Total Capacity: gallons <br /> (perdank or cumulative for containers by product type) Install Date: <br /> hf. <br /> I <br /> ❑ Tank (2$20) El Containers (2821) <br /> #of Containers:, TA#: ' <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) c <br /> Install Date: <br /> ❑ Tank (2820) ❑ Containers (282.1) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: , ? ®� gallons Total Capacity for Site: - d d gallons <br /> Comments: <br /> I <br /> EHD inspector: Reviewed Date: Entered Date: <br /> ' u By Initial: .�.r6,t By Initial: !,C <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br /> "Container means a storage device designed to�be moved when full. <br /> EHD 28-01 <br /> 09/12/08 <br /> AST SURVEY FORM <br /> a <br />