Laserfiche WebLink
#ENTORY RECONCILIATION <br /> QUERLY SUMMARY REPORT FORM <br /> Facility Name; American Savings Bank <br /> 1 Product - <br /> 119 x 210 Unleaded <br /> Facility /Address; 1888 Lockheed Court <br /> Stockton, Ca 95201-0300 <br /> Telephoner {209) 983-4120 <br /> ■ r r.ri r r rri <br /> Person Filing <br /> Report: Robert D. Kr zsko <br /> x I hereby certify under penalty of perjury that all inventory <br /> variations for the above mentioned facility were within the <br /> allowable limits for this quarter. (22 in column 13 of the <br /> Inventory Reconciliation Sheet, ) <br /> Inventory variations exceeded the allowable limits for this <br /> quarter. I hereby certify under pena.ity of perjury that the <br /> source for the variation was not due to authorized (leak) <br /> release. (XII in Coluign 13 of the , Inventory Reconciliation <br /> Sheet) . <br /> List date , tank i , amount for all variations and the reason <br /> for exceeding the allowable limits . <br /> P a t e Ia n k }` B�.QL�,11� Bea s RE) <br /> 1. <br /> 2 . <br /> 3 . <br /> 4 . <br /> 5 <br /> s <br /> Additional dates/amounts shall be continued on A separate <br /> sheet of paper and attached. <br /> If the source of the variation which exceeded allowable limits <br /> was due to a leak, the incident shall be reported to Publio <br /> Health Services of San Joaquin County Environmental Health. <br /> Division, within twenty-four ( 24 ) hours and an unauthorized <br /> release report submitted . <br /> The quarterly summary rep�otrt shall be submitted within fifteen (15) days of <br /> the end of each quarter . Circle appropriate quarter. <br /> =Quarter: - January---------->March <br /> Quarter 2 - April ----------->June <br /> Quarter 3 - July ------------>September <br /> Quarter 4 - October ---------->December f IT" <br /> Send to; SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION APR 4 Iggi <br /> 1601 E. Hazelton Ave , , P , O . Box 2009IVIa,, r <br /> Stockton, CA 95201 NTA . WEALTH <br /> ( 209 ) 468-3420 ;;� rl� /,�;FRVIcQKS <br /> EH 23 019 ( 10/89) <br />