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i�_ <br />INVENTORY RECONCILIATION* 0 CT 17 1,991 <br />QUARTERLY SUMMARY REPORT FO VIRONMENTAL HEALTH <br />Facility Name: i2ANKs i caU' n 11-3 1 PERI�AI17SERI od ct <br />00 1 02rrr7a <br />con <br />OC <br />L <br />Facility Address: q0 A r-�4 i� Si - <br />Telephone! <br />Person 1 n �--'- <br />Report: <br />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. (No in column 13 of the <br />Inventory Reconciliation Sheet.) <br />Inventory variations exceeded the allowable limits for this <br />quarter. I hereby certify under penalty of perjury that the <br />source for the variation was not due to authorized (leak) <br />release. (XS in Column 13 of the Inventory Reconciliation <br />Sheet) . <br />List date, tank ,J, amount for all variations and the reason <br />for exceeding the allowable limits. <br />0 <br />1. '7- <br />2. <br />3. P-1.5-9) <br />4. <br />5.-P- to -91 <br />Amount <br />Reason <br />1115 kcm <br />C -3/4a Loop <br />G PS I-On6 <br />G oS L'Ean <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 Public: <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 report shall be submitted within fifteen (15) days of <br />the end .of each quarter. Circle appropriate quarter. <br />Quarter 1 - January ------ <br />Quarter 2 - April ----------->June <br />Quarter 3 - July ------------>September <br />Quarter 4 - October --------->December <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />EH 23 019 (10/89) (209) 468-3420 <br />