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SAN JOAQUIN COUNTY ;NVIRONMENTAL HEALTH DEPARTMENT 'S60 East Main Street,Stockton,CA 95202-3020-w' Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjg0v.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Yana nn� CI KI S� ... Facility Addr 't ry h a Page�_Df c�Gls n City: FA#: l �l�''�CO /4Q.Q S� Inspecttiiongate: l./W p 7 ©C �,� Prog Element: Tank/Container Information 3 �- Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Com Tete one box for each tank or each cumulative container product e. Tank(2820) ❑ Containers (2821) 1 (>250 gallons) (>55 gallons and<250 gallons) #of Containers: TA#: Total Capacity: gallons O oo Product Type: t� (Per tank or cumulative to,c mers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: bs''q 3 (>250 gallons) (>SS gallons and<250 gallons) TA#: 2 Total Capacity: 15 '26 IDgallons Product Type: � --f– (per tank or cumulative contamcrs by product type) Install Date: �— ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: 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) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: O <5p'o gallons Continents: EHD Inspector. Reviewed Dat � Entered DateL: By Initial: D By Initial: L EHD 28-01 01/16/08