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INVENTORY RECONCILIATi <br />QUARTERLY SUMMARY REPORT !J <br />Facility Name: <br />Facility Address: 2705 C,-;fl�try CItt Biv,�, <br />Telephone: <br />Person Filin• <br />Report: <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. QLo 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 Reconcation <br />Sheet). <br />List date, tank #I amount for al . 1 variations and the reason <br />for exceeding the allowable limits. <br />Date Tank Amount Reason <br />-7-z- (arta cc -I A <br />2- ------ /< <br />z L-4- <br />3.-oJc 4� <br />4. <br />Emfta- <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 Wenty-four (24) hours and an unauthorized <br />release report submitted. <br />The quarterly summary report shall be submitted wn 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 <br />Quarter 4 - October <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />Box 2099,/ <br />Stockton, CA 9 -5 -201 --- <br />EH 23 019 (10/89) (209) 468-3420 <br />