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1 <br /> dbTVENTORY RECONCILIATION <br /> SUMMARY REPORT FORt* <br /> le: <br /> Facility , ., i Tank 9i Size i Product i <br /> Facility Address: <br /> Telephone: <br /> Person Filing,' <br /> Report: ti - <br /> D <br /> / I hereby certify under penalty of perjury <br /> variations for the above mentioned t "a10a }�+emY <br /> ✓ facilit e'irA e <br /> allowable limits for this quarter. (No in col2lg 19P the <br /> Inventory Reconciliation Sheet. ) - <br /> ENVIR()fmMi.IV TNS. 0"I-1'I i <br /> tZInventory variations exceeded the allowable PE*t&+6 diW kis <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) . <br /> List date, tank f, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Date Tank Amount Reason <br /> 1. - till, <br /> 2. <br /> 3 . UAtt <br /> 4 . / <br /> 5. 1 ' <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 /> Quarter 2 - April ----------->June <br /> Quarter 3 - July ------------>September <br /> Quarter 4 - October --------->December <br /> Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. Hazelton Ave. , P.O. Box 2009 <br /> Stockton, CA 95201 <br /> (209) 468-3420 . <br /> EH 23 019 (10/89) <br />