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SAN JOAQUIN COUNT* <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: //+ /py1 ./ ^f��' Page d of J <br /> r� C / I � r Y I' <br /> Facility Address: City: �S C'/ Inspectio 2 te:t7 <br /> FA#: PR M PrograM Element. <br /> 1 / 7 PT3eqfol I --L-1Ll--o <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum x1,320 gallons in tanks`and containers**. <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank (2820)•-, ❑ Containers (2821) #ofi Containers: ----- <br /> 1 <br /> ontainers: ----- #: <br /> 1 Total Capai <br /> city: tr ) gallons Product Type: <br /> (per tank or cumulative for containers-by product type) Install Date: <br /> ❑ Tank (2 20) El Containers (2821) <br /> #of Containers: TA#: <br /> 2 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: TA#: <br /> 3 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> C] Tank (2820) ElContainers (2821) #of Containers: TA#: <br /> 4 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> _ ElTank (2820) ElContainers (2821) #of Containers: TA#: <br /> 5 Total Capacity: gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: i <br /> Total Capacity this Page: ; gallons Total Capacity for Site: gallons <br /> Comments: <br /> i <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: <br /> i <br /> "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleu . <br /> "Container means a storage device designed to be moved when full. <br /> EHD 28-01 AST SURVEY FORM <br /> 091121o8 <br />