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MONITORING ALTERNATIVE #5 <br /> Wventory Reconciliation <br /> Quarterly Summary Report Form <br /> ,((. <br /> !! Tank# Size <br /> ff4 Product <br /> Facility Name: S�r7 ;1o/�y)d/J <br /> Face} y Address: '6-, N "`cm, <br /> / dry7�Cca Ca �/ Y3.-(,--- <br /> � _ <br /> Telephone: 4109 - Vim✓ A{ - 35-W K <br /> Person Filing Report: T&1,4y U)o�r�0_41 <br /> I hereby certify under penalty of perjury that all inventory 00409WFOR HEALTH <br /> above mentioned facility were within the allowable limits for tIOERMffr G3'ERVICES <br /> (NO in column 13 of the Inventory reconciliation Sheet.) <br /> Inventory variations exceeded the allowable limits for this quarter. 1 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 Slieet.) <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 � March <br /> Quarter 2: April 0 June <br /> Quarter 3: July t September Y <br /> Quarter 4: October t December <br /> r <br /> Send To: <br /> San Joaquin County Public Health Services <br /> Environmental Health Services <br /> Post Office Box_ 2009 <br /> Stockton, CA 95201 <br /> (20) 468-3920 <br /> EHS 23 019 10/86 <br />