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INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: yRi•XV4000S D�V_u <br />♦ dress: <br />I <br />winmj-�� <br />Zerson Filing 'A e <br />Report: <br />I hereby certify under penalty of perjury that all inventory <br />40� 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 th4 <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 f, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date Tank_t Amount <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 dent 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 I - January ---------- >March <br />Quarter 2 - April ----------- >June <br />Quarter 3 - July ------------> epte ber <br />Quarter 4 - October --We ----- >December e�kz"' <br />0 <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH ENVSERVICEkj��' �'*)l 4�- <br />IRONMENTAL HEALTH DIVISION W, <br />7 <br />1601 E. Oto <br />ktoon, CAv,9520O.1 Bx 20091,A <br />EH 23 019 (10/89) (209) 468-3420 <br />