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%-0' INVENTORY RECONCILIATION <br /> �Y <br /> SUMMARY REPORT FORM <br /> Facility Name: <br /> 41 - Tank Size i t <br /> '"\Facility Address: <br /> Telephone: <br /> Person Filing <br /> Report: <br /> QI 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. ( I-o in column 13 of the <br /> Inventory Reconciliation Sheet. ) <br /> i <br /> QInventory 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 e Amount Reason <br /> 2 . <br /> 3 . Loj 4b <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 _ <br /> Quarter 2 - April ----------->June <br /> _ Quarter 3 July ------------>September <br /> Quarter 4 .-:October ----->Decamber r <br /> -w <br /> C*Rnd to: ; SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' <br /> ENVIRONMENTAL HEALTH DIVISION._ <br /> 1501 E. Hazelton Ave., P.O. .Box 2009 y. <br /> Stockton, CA 95201 <br /> (209) 468-3420 <br /> EH 23 019 (10/89) <br />