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SAN JOAQUIN 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.sigov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> R-p Page of <br /> Facility Address: City: Inspection Date: <br /> 4� C <br /> �Z. <br /> FA M PR#: <br /> /� I /1 Pro ram ElZ_ <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers". <br /> Complete one box for each tank or each cumulative container product type, <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 1 Product Type:OAP(d /fl / �>a <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 2 Product Type:g�Ylt M <br /> Total Capacity: �k gallons <br /> (per tank or cumulative for containers by product type) Install Date:_12/ <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: 66_a DDS a <br /> 3 Total Capacity: gallons Product Type: P�,(tp„� Chi <br /> (per tank or cumulative for containers by product type) <br /> Install Date: <br /> ,Fz'Tank (2820) ❑ Containers (2821) #of Containers: TA#: S 2pD ;Z 3 <br /> 4 Total Capacity: gallons Product Type: dc,%,a, <br /> (per tank or cumulative for con ainers y product type) ' <br /> <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: /9,50 ,90'9' <br /> 5 Total Capacity: L500 gallons Product Type: J I E��- <br /> (per tank or cumulative for containers by product type) o -� <br /> Install Date: <br /> Total Capacity this Page: Z'3 I D gallons Total Capacity for Site: r7d gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Datgf e: <br /> By Initial: R� '21 3I 10 By Initial: l <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. T <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />