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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEIS „ <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 Mame: ! <br /> G r 7 ��D Page l of <br /> U 5 C !J r T <br /> Facility Address: City: Inspectio Da <br /> ! S S d G , `ver r RI ib 2 n$ <br /> FA 1'R <br /> P ram Element: <br /> #: #: �. � <br /> Z <br /> b <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage'. <br /> torage of petroleum 21320 gallons in tanks and containers over 55 g ns. <br /> Com etc one box for each tank or each cumulative container product <br /> F ❑ Tank(2 20) Contain (282 #of Containers: --ZP' TA#: <br /> (>250 gallons) (>55 llons and 50 gallo } <br /> 1 � Product Type: � <br /> Total Capaci gallo s <br /> (per tank or cumulative for containers by product type) Install Date' <br /> ❑ Tank(2820) containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 uct'Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers ntais by product type) Install Date: <br /> ❑ Tank(2820) 06ontainers (2821) #of Containers: Y TA#: <br /> ` (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: j/_(7 gallons <br /> (par tank or cumulative for containers by product type) Install Date: d <br /> ❑ Tank(2820) O Containers (2821) #;Df Containers: TA#: <br />+ (>250 gallons) (>55 gallons and<50 gallons) <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: TAM <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: SD O gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Tota[Capacitythis Page: l�-1 gallo%ns Total Capacity for Site: ['z-t 6 gallons <br /> Comments: <br /> or <br /> _ v <br /> EHD Inspector: Reviewed - Date: Entered Date: <br /> C 3 l�' 11 say Initial: 0 BY Initial: <br /> "EHD 28-01 <br /> 01/16/08 <br />