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4hECEIVED <br />INVENTORY RECONCILIATION <br />VngZT-E-RLY SUMMARY REPORT FORM APR 4 1991 <br />Facility Name: <br />Facility Address: <br />Telephone: <br />Person Filing ------T-- <br />Report: VVSC, --aN�-Vf <br />I- I, It i A - - <br />I Hereby certify under penalty of perjury that all inventorT <br />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 dueto authorized (leak) <br />release. (Yes in Column 13 of the Inventory Reconciliation <br />Sheet). <br />List date, tank f, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date Tank <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 tw�enty-four (24) hours and an unauthorized <br />c�elease report submitted. <br />The quarterly summary report shall be submitted within fifteen (15) days of <br />the end of each are. Circle appropriate quarter. <br />Quarter 1 -January ---------- >Marc <br />Quarter 2 - April ----------- >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 />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />EH 23 019 (10/89) <br />