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INVENTORY. RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: af Tank S ' ze <br /> Product <br /> �y n <br /> Facility Address: 3O / .N r,f ��i <br /> Telephone: <br /> Person Filincr � a� <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. (Yes in Column 13 of the Inventory Reconciliation <br /> Sheet) . <br /> List date, tank #, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> G Date Tank Amount Reason <br /> A: A.Aa J <br /> I ` 1 <br /> 5. <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 /> Che quarterly summary report shall be submitted within fifteen (15) days of <br /> =he end of each quarter. Circle appropriate quarter. + - <br /> C��C,1C�.C�-�C <br /> Quarter 1 - January---------->March <br /> Qua:,t,_2. .c_.8pxi1 --------->June_...,. v `� <br /> garter 3 - July --------sSeptember <br /> ;end to: SAN JOAQUIN PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. Hazelton Ave. , P.O. Box 2009 � <br /> Stockton, CA 95201 <br /> (209) 468-3420 <br />