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$[40NITORING ALTERNATIVE #5 , _ <br /> Inventory Reconciliation OCT 0 '1 <br /> r-0"" <br /> Quarterly Summary Report Form FNVIRONMEK AL HEALTH <br /> eEnProd eRVICt� <br /> Tank# Size Product <br /> Ki9aDD t`'O�ol )� <br /> Facility Name: <br /> Faci}i y Address: , a <br /> /`lanfe�a Ca 4'.S33L <br /> Telephone: 1207— a3g'3S& ( <br /> Person Filing Report: Je-ISA W,/' K L <br /> I hereby certify under penalty of perjur that all inventory variations for the <br /> above mentioned facility were within the allowable limits for this quarter. <br /> (NO in column 13 of the Inventory Reconciliation Sheet.) <br /> Inventory variations exceeded the allowable limits for this quarter. I hereby <br /> ❑ certify under penalty of perjury that the source for the variation was not due <br /> to unauthorized (leak) release. (YES in Column 13 of the Inventory <br /> Reconciliation Sheet.) <br /> List date,tank number, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank# Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <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 0 March <br /> Quarter 2: April June <br /> Quarter 3: July t September <br /> Quarter 4: October I) December <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 /> EHS 23 019 10/86 <br />