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VOW SAN JOAQUIN COUNTY %one ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: KA RL l: S 50tJ5 N Page f of Facility Address: City: Inspedo Dat . 3 0 0 FA#: PR#: Program Element. 2zz 0 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks`and containers". Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#:�fy 1 Total Capacity: 6-0 gallons Product Type: 1 0 (per tank or cumulative for containers by product type) Install Date: P/Tank (2820) ❑ Containers (2821) #of Containers: TAM 2 Total Capacity: 3 -;'d gallons Product Type: �� S (pertank orcumulative for containers by producttype) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: p gallons Total Capacity for Site: gallons Comments: NSF/V z� 3'- ZY \ EHD Inspector: ,p /� Reviewed Date: J Entered Date: 9/ By Initial: By By Initial: 0 B 'Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08