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,.INVENTORY RECONCILIATION .� <br /> QUARTERLY SUMMARY REPORT FORM <br /> Facility Name: _�/ � 5 / G r �o�/ Tank # Size Product <br /> U crst-) L <br /> Facility Address: )off to ) / �1 S T z - f <br /> c_ i'_)- 7 o vvrJ <br /> Telephone: �2Ci- 3 )_ ? o <br /> Person Fid}ng <br /> Report: X1/1 aN�- yz ;'S Qz92L'/ <br /> I ereby certify under penalty of perjury that all inventory <br /> riations 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 /> Date Tank # Amount Reason <br /> SEP 2 4 1ac9 <br /> ENVIRONMENTAL <br /> S <br /> PER, <br /> N ERV CESE3.y <br /> 4 . <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 /> 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 /> -6- - <br /> ��_er ----------->Ju��� <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 />