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ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name:��'"! C O � iT bbl -- Page r� of _ A �s�i iJ �� C Enspectioii Date: Facility Address: City: ir �; Gtr ZQ - )/ Program Element: Complete for all sites with cumulative aboveground storage of petroleum >_ 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. [ � Tank (2820) ❑ Containers (2821) #of Containers: TA#: 15.aA)7" ,7A2ZC >2gallons) (>55 gallons and <250 gallons) � (50 g Product Type: - 1 U gallons Total Capacity: tom" L g Install Date: (per tank or cumulative for containers by product type) "I-- .. v EYf ank (2 820) ❑ Containers (2821) #of Containers: TA#: 5--5-1 t°g >� (>250 gallons) (>55 gallons and <250 gallons) Product Type:' Total Capacity: Z. -U G a gallons Install Date: (per tank or cumulative for containers by product type) wank (2820) - ❑ Containers (2821) #of Containers: o TA#• ! /� (>250 gallons) (>55 gallons and <250 gallons) 3 Product Type: Z-5 Total Capacity: 1.-- ®fit D gallons Install Date: (per tank or cumulative for containers by product type) Ee T ank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 4 Product Type: Total Capacity: % O d D gallons Install Date: (per tank or cumulative for containers by product type) Vank (2820) ❑ Containers (2821) (>250 gallons) (>55 gallons and X250 gallons) 5 Total Capacity: gallons (per tank or cumulative for containers by product type) Total Capacity this Page: Comments: EHD EHD 28-01 01/16/08 #of Containers: TA#: 19 L5-) le/ Product Type: Install Date: gallons Total Capacity for Site: 1?® gallons 12o sN' r show LIP od I wyr(vTot�y ,01)9 —o- Reviewed nt Date Eered Dale. )ectol� '1 _3 By Initial: By Initial