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INVENTORY. RECONCILIATION <br /> [� QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: i�r _ T-� Tank size Product <br /> O <br /> Facility Address: / <br /> Telephone: 94//2/!/'7/ <br /> Person Filing <br /> Report: 45�Z� <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. ( INo, 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 /> Date Tank Amount Reason <br /> 3.10 <br /> 4. <br /> Additional dates/amounts shall be cont nued o4a 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) hour 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---------->March <br /> Quarter 2 April >June '— <br /> tar._�._.,--��r3y--�==_-_==--=->Septem'bd1'"'� •�_ <br /> Quarter 4 - October --------->December <br /> Send 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 />