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&VENTORY.RECONCILIATION • <br />QUARTERLY SUMMARY REPORT FORM <br />Wacility Name: �f.'A-C�� SOE Tank Size <br />Facility Address: 3 7 -S- <br />y <br />4 ,ter <br />Telephone: <br />Person ct <br />Filin <br />R <br />Re ort ort : �' <br />I hereby certify under penalty of perjury that all inv-n <br />y <br />� <br />variations for the above mentioned facility were'n <br />allowable limits for this quarter. (No in column <br />Inventory Reconciliation Sheet.) APR 2 7 <br />Inventory variations exceeded the allowable limjL-WOp o r�Mi AL HEALTH <br />quarter. I hereby certify under penalty of perjur}P EIR <br />d V/5 <br />source for the variation was not due to authorized k) <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 Amount Reason <br />1. <br />• 2. <br />3. <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 ---------- >March <br />Quarter 2 - April ----------->June <br />Quarter 3 - July ------------>September <br />• Quarter 4 - October ------=-->December <br />Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />