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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />F4ciUty. Name: PUBLIC WORKS <br />lacilityAddresfi: 1810 E. HAZELTON <br />SILL -KION CA 95205 <br />Telephone: 468-3074 <br />Person Filing <br />Report JUNE OKUBO <br />10 <br />S <br />Product <br />0 NO LEAD <br />0 REGULAR <br />❑ 1 hereby certify under penalty of perjury that all inventory variations for <br />the above mentioned facility were within the allowable limits for this <br />quarter. (No in Column 13 of the Inventory Reconciliation Sheet) <br />❑ Inventory variations exceeded the allowable limits for this quarter.- I , <br />hereby certify under penalty of perjury that the source for the variation <br />was not due to as unauthorised (leak) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) , <br />List date, tank ft and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank f Amount 9199199 <br />1 V <br />• 7-7_ 89 2 196 0 <br />2. 9=15-89 2 343 <br />OCT 0 61989 <br />3. ENVIRONMENTAL HEALTH <br />PERMIT / SERVICES <br />4. <br />5. <br />Additional dates/amounts shall be continued on a separate sheet of <br />Paper snd attached. <br />If the source of the variation which. exceeded allowable limits was due to <br />a leak the incident shall be reported to S.J.L.H.D. Environmental Health <br />within 24 hours and an unauthorized release report submitted. <br />the Quarterly summary report shall be submitted within 15 days of the end of each <br />Quarter. <br />Quarter 1 - Jaauary --> March <br />Quarter 2 - April --) June <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Haze 1 coli , P.O. Rox 2009 <br />Stockton. CA 95201 466-6761 <br />EH 23 019 10/846 <br />