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SAN JOAQUIN COUNTY <br /> = itJVIRONMENTAL HEALTH DEPARTMEN' <br /> '000 East Main Street,Stockton,CA 95202-302ro <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 /> Q rVi� a 1 IQ 7/D Page of <br /> Facility Address: C_ ity;—� Inspectipn Jaa[e: <br /> FA#: Z ! t7PR#: c7,'O/ PrograQDm/E/IecmTe/ntr D <br /> o6 d O zg v <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 <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: /9.5l7 D q 7 <br /> (>250 gallons) (>55 gallons and<250 gallons)a n � <br /> 1 Product Type: _� On_arc/ <br /> 1 <br /> Total Capacity: / O d Cjgallons _ <br /> (per tank or cumulative for con/tamers by product type) Install Date: <br /> ❑ Tank (2820) lr Containers (2821) #of Containers: TA#: <br /> 2 <br /> (>250 gallons) (>55 gallons and<250 gallons) Z'/C'Z'/C' C'/ l✓ <br /> - <br /> —_— <br /> Total Capacity: gall <br /> - - n_ -- - D/LA <br /> (pr tank or cumulative for containers by product type <br /> 2---Tank <br /> eTank(2820) ❑ Containers (282 1 TA#: <br /> (>250 gallons) (>55 gallons and<250 gallot — <br /> 3 Total Capacity: o-d ->7&- ,& <br /> gallo <br /> (pa tank or cumulative toiners by product type) <br /> Tank(2820) ❑ Containers (2821) #of Containers: TA#: F p <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Total CaProduct Type: /y/4,ST,E 0,; L <br /> pacity_•-�y D gallons <br /> (pe,ta orEu'mulative for containers by product type) Install Date: <br /> ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> Total Capacity this Page: gallons Total Capacity for Site: 6 gallons <br /> Comments: <br /> D ` N / <br /> vo YL, Ib I !l J <br /> EHD Inspector: N Reviewed Date: Entered Date: <br /> By Initial: Q.Cy OrG By Initial: d <br /> EHD 28-01 D <br /> 01/16/08 <br />