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INVENTORY RECONCILLATZOh--'0' <br /> u4A=RI-11�Y SUMMARY REPORT FORM <br /> �nrva <br /> Facility Name: �- <br /> /y <br /> ! i'alC C• <br /> Facility Address: <br /> Telephone: <br /> Person Filing <br /> Report: <br /> U T hereby certify under penalty' of perjury that all inventory <br /> �-J variations for the above mentioned facility were within the <br /> allowable limits for this quarter. (No in column 13 of the <br /> Inventory Reconciliation Sheet. ) <br /> Q L <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 va_rlations and the reason <br /> for exceeding the allowable limits. <br /> Bate <br /> Tank mount Reason <br /> 1.2 rr�,L�'iYihl 1 t - <br /> z :�,. <br /> je- <br /> 4 . <br /> Additional dates/amounts shall be. ccntinued 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 <br /> the end of each quarter. Circle appropriate quarter. (15) days of <br /> Quarter 1 - Tanuary---------->March <br /> Quarter 2 -- April ----------->June <br /> Quarter 3 - July ------------>September <br /> Quarter 4 - October --------->December <br /> h,_"end t4: SAN JOAQUINCOUNTY PUBLIC HEALTH SE- VICES _ <br /> ENVIRONMENTAL, HEALTH DIVISION <br /> E. Hazelton Ave. , P.O.- Box 2009 - w- <br /> Stockton, CA 952oi - -- <br /> 23 01s (10/89) (209) 468-3420 <br />