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0 INVENTORY.RECONCILIATION mc%e <br />QUARTERLY SUMMARY REPORT FORM JAN 0 7 1992 <br />Facility Name: t? ENVIRONIMS� NL H E A Ur L <br />TAnk # <br />ct <br />odu <br />Facility Address: WIC12 &/. <br />Telephone: <br />Va <br />Person Filing <br />Report:%A6c- A, e <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. (1_42 in column 13 of the <br />Inventory Reconciliation <br />Inventory variations exceeded the allowable limits for this <br />quarter. I hereby certify under penalty of perjury that thq <br />source for the variation was not due to authorized (leak) <br />release. (Y—e_s 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 />2. <br />3. <br />0 <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 whichexceeded 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 --;K ------ >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 />