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• INVENTORY RECONCILIATR <br />• QUARTERLY SUMMARY REPORT FORM <br />Facility Name: f7 L'',n tI2 �`�r2 s K Tank # i <br />Facility Address: 2-7os Ccu, r Tiz !1ak, <br />cD� <br />Telephone: <br />Person Filing <br />Report: _- ,, . y p, 1, 4, <br />(-1 I hereby certify under penalty of perjury that all inventory <br />(--J 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 #, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date Tank Amount_Reason <br />1. �}Ql2�L /N ACCO-cr2�r� <br />iv/�ccu✓L/1 /%r��, <br />L 2 • <br />3. .3 4 121p 1 � <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 -------- <br />--->June <br />Quarter 3 - July ------------>September <br />Quarter 4 - October --------->December <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1-601—E —11agelton-,Ave .2009 <br />Box - - -- ox 2 0 9 <br />.0_. � <br />Stockton, CAS 01�� <br />EH 23 019 (10/89) (209) 468-3420 <br />t'i UQUCL I <br />(-1 I hereby certify under penalty of perjury that all inventory <br />(--J 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 #, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date Tank Amount_Reason <br />1. �}Ql2�L /N ACCO-cr2�r� <br />iv/�ccu✓L/1 /%r��, <br />L 2 • <br />3. .3 4 121p 1 � <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 -------- <br />--->June <br />Quarter 3 - July ------------>September <br />Quarter 4 - October --------->December <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1-601—E —11agelton-,Ave .2009 <br />Box - - -- ox 2 0 9 <br />.0_. � <br />Stockton, CAS 01�� <br />EH 23 019 (10/89) (209) 468-3420 <br />