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r 010NITORING ALTERNATIVE $5 . <br /> 'y Inventory Reconciliation <br /> Quarterly Summary Report Form <br /> / Tank# Size Product <br /> Facility Name: 4 5V/J a G <br /> Facility Address: '157 N. A2Ih �t' <br /> /?'lmn e(a Ca lt736 <br /> Telephone: ✓04 —339- M01 <br /> Person Filing Report: Tem q W0/0!()S <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 /> (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 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 /> and attached. <br /> paper <' • ti, ���. <br /> If the source of the variation which exceeded allowable limits was due to kt/ <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 June <br /> Quarter 3: July September <br /> Quarter 4: October 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 /> FHS 23 019 10/86 <br />