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SAN JOAQUIN COUNTY I* <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.orglehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: 1 <br /> At,04. „r' L L G Wage of..--�-- <br /> Facility Address: City: Inspection Date: <br /> FA#: PR#: Program Element: <br /> © . J <br /> Tank/Container information <br /> Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks* and containers**. <br /> Com fete one box for each tank or each cumulative container productlype. <br /> ❑ Tank (2820) /-'fa Contai er 2821) #of Containers: TA#: i96-j !?,3 7 <br /> Total Capacity: /�/pp gallons Product Type: _t '';esc1 ��, e„,s <br /> (per tank or cumulative for containers by product type) <br /> Ins ate: <br /> ❑ Tank (2820) Containers (2821) #of Containers.- <br /> 2 Total Capacity: 0 gallons Product Type: <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 3 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) ✓ N <br /> Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 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 /> 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: [�� gallons <br /> Comments: <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: } ls71)•I 0 By Initial: O� <br /> *Abov round storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. 0 <br /> "Conlainer means a storage device designed to be moved when full. <br /> EHD 28-0'1 <br /> 09/92108 AST SURVEY FORM <br />