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ENTORY ,R:-409CILIATION <br /> { SUMMARY REPORT FORK <br /> Facility Name: _� - > i Tank # i Size i Product i <br /> r- <br /> u Facility Address '? <br /> W11 <br /> Telephone: <br /> Person Filing <br /> Report: z �; <br /> a / I hereby certify under penalty of perjury that all inventory <br /> ✓ variations for the above mentioned facility were within the <br /> allowable limits for this quarter. (No in 3 of the <br /> Inventory Reconciliation Sheet. ) , <br /> ❑ ✓ Inventory variations exceeded the allowable li s� JtI this <br /> quarter. I hereby certify under penalty of peYty t the <br /> source for the variation was not due to &&MBe[We"TMefa9ALTH <br /> release. (Yes in Column 13 of the Inventor?ERNPpT540��on <br /> Sheet) . <br /> List date, tank #, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Date Tank Amount Reason <br /> 1 <br /> c. <br /> 2. <br /> 4 . <br /> 5. <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 />