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NVENTORY,RECONCILIATIOI� <br />QUARTERLY SUMMARY REPORT ;10 <br />Facility Name: IGHN TAY! <br />Facility Address: OfSTOCKT.N <br />Telephone: <br />Person Fil <br />Report: _ <br />4W <br />J U L 1 0,^"1 <br />ENVIRONMENTAL HEALTH <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. (Lo 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 0, amount for all variations and the reason <br />for exceedinq the allowable limits. <br />Date <br />1. 30 Q <br />2. <br />3. <br />4.�— <br />5, 6 0 <br />Tank Amount Reason <br />Z -q9- <br />3 <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 />uivision, 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 ---------- >March <br />Quarter 2 - April ----------->June <br />Quarter 3 - July ------------>September <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 />