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Facility Name: <br />/ W,TA <br />Facility Address: <br />Telephone: <br />Person Filin�jy/ �g, <br />Report: //[ dA <br />INVENTORY.RECONCILIATION' <br />QUARTERLY SUMMARY REPORT FORM <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. (iso in column 13 of the <br />Inventory Reconciliation Sheet.) <br />QInventory variations exceeded the allowable limits for this <br />quarter. I hereby certify under penalty of perjury that the <br />sourcesfor the variation was not due to authorized (leak) <br />release. (Yes in Column 13 of the Inventory Reconciliation <br />Sheet). ' <br />List date, tank 1, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date Tank Arount Reason <br />miu, <br />2.7-17V 7-.7-s -tr 1 Ula j <br />3. U►t�7-zq-9Z <br />4.S-/ To 9"1Sj7,19 �r / hty_ Tari -t I -havt /Mg -k <br />5.9-,Z2 7y 4-3b... 4T-7' Td n 2i T <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 />k1lease 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=Apx>>----------- >June v <br />4uarter 3 - July ------------- >Septembe <br />Quarter 4 - October --------->December OCT 0 81992 <br />Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES ENVIRONMEWX HEALTH <br />ENVIRONMENTAL HEALTH DIVISION pERMI(/8ERVICES <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />