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SAN JOAQUIN COUNTY 2 NVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: o 4' G %ic�•> c _ J /�` Page '--�—of R• Facility Address: City: Inspection D te: FA #: PR #' Pr—.— Flomont• / D5�Qg 4? Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ;�- 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. ank (2820) ❑ Containers (2821) #of Containers: TA#: "- 1 (>250 gallons) (>55 gallons and Q50 gallons) Product Type: /A/ /I ,S' 7--"0C 0/, Total Capacity: 2- T- 0 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 2 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 3 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) a ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: gallons install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: ,�� gallons Total Capacity for Site: gallons Comments: -- a EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: EHD 28-01 01/16/08