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INVENTORY. RECONCILIATION APR 2 5 e^A1 <br /> QUARTERLY SUMMARY REPORT F9WONMENTAL HEALTH <br /> Facilityy Name: jWAXt'l6T' Tank # size t' Product <br /> &W 0 j" I L,- C1� <br /> Facility Address: SWSS, nG.� w„moo E /R, <br /> /7G A/,-” (.fes=::U' �A7 n 7 � J3ra <br /> Telephone: 9 L2- OS y <br /> Person Fi 'ng � <br /> Report: <br /> 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. (Ho in column 13 of the <br /> Inventory Reconciliation Sheet. ) <br /> Inventory variations exceeded the allowable limits for this <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 #, amount for all variations and the reason - <br /> for exceeding the allowable limits. <br /> Date Tank # Amount Reason <br /> 1. <br /> 2. <br /> 3 . <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 /> c Quart January---------->March <br /> Quarter 2 - April ----------->June <br /> Quarter 3 - July ------------>September <br /> Quarter 4 - October --------->December <br /> Send to: SAN JOAQUIN 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 />