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• <br /> MONITORING ALTERNATIVE #5 <br /> Inventory Reconciliation <br /> Quarterly Summanj Report Form <br /> Facility Name: <br /> Tank# Size Product <br /> � �i,.,., s �,� , ,_ <br /> Facility !!iAddress: <br /> pc � <br /> Telephone: <br /> Person Filing Report: jg <br /> I hereby certify under penalty of perjury that all inventory variations for the <br /> above mentioned facility were within the allowable limits for this quarter. <br /> (ND in column 13 of the Inventory Reconciliation Sheet.) <br /> Inventory variations exceeded the allowable limits for this:gtiarter. 44 4 y <br /> certify under penalty of perjury that the source for the variation was not ue <br /> to unauthorized (leak) release. (YES in Column 13 of the Inventory..`,, <br /> Reconciliation Sheet.) <br /> HEAU' <br /> List date, tank number, and amount for all variations that eice 'ded' i` <br /> allowable limits. <br /> Date Tanis# Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. ..._ <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which exceeded allowable limits was due to a leak, <br /> the incident shall be reported to San Joaquin County Public Health Services; <br /> Environmental Health Services, within twenty-four (24) hours and an <br /> unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within fifteen (15) days of the end of <br /> each quarter. <br /> Quarter 1: January March <br /> Qarter 2: April June <br /> uarter 3; ul Se tember <br /> V� uarter 4: October December <br /> 1� <br /> Send To: <br /> San Joaquin County Public Health Services <br /> Environmental Health Services <br /> Post Office Box 2009 <br /> Stockton, CA 95201 <br /> (209) 468-3420 <br /> FHS 23 01910/86 <br />