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SAN JrUd&rT Ask- <br />QWIN COUNTY PUBLIC HEALTH MVICES <br />VVIRONMENTAL HEALTH DIVISIff <br />ANNUAL INVENTORY RECONCILIATION SUMMARY REPORT <br />California UST Regulations, Article 4, Section 2646(j) <br />Facility Name <br />Address <br />LZ City <br />All inventory variations for the above mentioned facility were <br />within allowable limits of Title 23, California Code of Regulations, <br />Division 3, chapter 16, Section 2646, for the 12 month period from <br />A 19 to eC, 31 <br />Inventory variations in excess of the allowable limits of Section <br />2646, occurred as listed below. <br />I DATE I TANK # / PRODUCT I AMOUNT (Gallons) I <br />Submit report within 15 days following the end of the last month of the <br />12 -month period covered by the report. Report to be submitted to: <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388 ' <br />STOCKTON, CA 95201-0388 <br />I certify under penalty of perjury, that all variations (if any) <br />exceeding allowable limits are indicated above (California Health & <br />Safety Code, Section 25299): <br />Facility Tank Operator/Owner <br />EH 23 019 8-1-92 <br />2t7/c?� <br />Date <br />