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INVENTORY RECONCILIATION- <br /> .UARTERLY SUMMARY REPORT F,r11 <br /> Facility Name: S40C Lkh Tko Deet— Tank # Size Produc <br /> c� ,e <br /> Facility Address: <br /> Telephone: Z <br /> Person }p <br /> Report: y W- <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 /> Sheet) . NDS tKC4 <br /> List date, tank #, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Date Tank Amount Reason <br /> 1. <br /> 2. <br /> 3 . <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 /> April <br /> Quarter 3 - July ------------>September >�,nP13 <br /> Quarter 4 October >DecemberH1JV3H 3dlf <br /> Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES Lf 'ti < < Ngd fg ■ <br /> ENVIRONMENTAL HEALTH DIVISION tM <br /> 1601 E. Hazelton Ave. , P.O. Box 2009,.. <br /> Stockton, CA 95201 <br /> (209) 468-3420 <br />