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4 iM4� Z ol -2— <br />INVENTORY.RECONCILIATIO UARTERLY SUMMARY REPORT FIt awr-Ir-K I/ /I I I <br />Facility Name: &i&w Tank # <br />'D' Ze" Alm <br />Facility Address: 4thlell <br />Telephone: <br />Person Filing <br />Report: q <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. (No 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 #j amount for all variations and <br />for exceeding the allowable limits. <br />Rate Ta <br />AMpunt <br />1. <br />2. <br />3. <br />4. <br />5. <br />the reason <br />Reason <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 />- <br />The quarterly summary report shall be submitted within fifteen (15) days of <br />the end of each quarter. Circle appropriate quarter. <br />Quarter <br />Quarter 2 - April ----------- >June <br />>September <br />Quarter 4 - October <br />Send to: SAN JOAQUIN PUBLIC HEALTH SERVICESRECEIVED <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. Box 2 09 JAN 09 1992 <br />Stockton, CA 95201 TINVIRONMENTAL HEALTH <br />(209) 468-3420 PERMIT/SERVICES <br />