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�aw INVENTORY RECONCILIATI-, <br />1% Su'T TERLY SUMMARY REPORT FOi?M <br />Facility Name: JOHN TAYLOR FERTILIZERS an Size <br />Facility Address: P. O. BOX 6098 <br />Telephone: _ <br />Person Filing <br />Report: <br />R <br />7So a <br />lle <br />a mm o <br />�n <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 />Si.c(::t) . <br />List date, tank #, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date <br />1. 5� / O <br />2 . / / ?O <br />3. X90 <br />4 <br />5. <br />Tank <br />Z <br />9 <br />Amount <br />Reason <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 />Heaith Services of San Joaquin County Environmental Health <br />Division, within twenty-four (24) hours and an unauthorized <br />release report submitted. <br />t � <br />The g1aari:erly summary report shall be submitted within fifteen (15) days of <br />the end of eaoh quarter. Circle appropriate quarter. <br />Quarter 1 - January ---------- >March <br />Quarter 2 - April ----------->June <br />Quarter 3 - July ------------>September' <br />' aq <br />Quarter 4 - October --------->December <br />J U L 10 ,ssn <br />Send to: SAN JOAQUIN PUBLIC HEALTH SERVICEs:_ONMENTAt HEALTH <br />NVIR <br />ENVIRONMENTAL HEALTH DIVISION PERMITNTAL CES <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />