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f <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />FacilitT Name: PUBLIC 14ORKS <br />Tank <br />P4cilitr4ddresi: <br />1810 E. HAZELTON 1 <br />STOCKTON; CA 95205 3' <br />Telephone: 468-3 07 4 <br />Person Filing <br />Report <br />JUNE OKUBO <br />Size <br />12,001 <br />C� <br />Product <br />ese <br />❑ I hereby certify under penalty of perjury that all inventory variatioas for <br />the above mentioned facility were within the allowable Limits for this <br />quarter. (Ko 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 an unauthorized (leak) releise. (Yes in Column 13 of the <br />Inventory Reconciliation Sheet) a <br />List date, tank to and amount for all variations that exceeded the <br />allowable limits. <br />Date Tank Amount <br />1. 5-9-89 3 88 Gals <br />2. 6-21-89 2 121 Gals <br />3_ <br />4. <br />S. <br />Additional dates/amouats shall be continued on a separate sheet of <br />paper and 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.1i.D. EavieonmentaL 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 i - January March <br />-QUArtec <br />Quarter 4 - October --> December <br />Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. haze1Lon, P.O. Rox 2009 <br />Stockton, CA 95201 466-6761 <br />EH 23 019 10/86 <br />