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fx 7�` <br />INVENTORY.RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility va e: <br />7 '/,2 y- 3. S <br />Facility Address: c15 -?,i& <br />Telephone: �q 310T <br />Person Filing <br />Report: <br />9 <br />I hereby certify under penalty of perjuryEt#Wp4WZ <br />v4%MC Efi <br />variations for the above mentioned facility pogMIT e <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 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 Amount Reason <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 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 />Send to: . <br />Quarter 1 - January ---------- >March <br />Quarter 2 - April ----------- >June <br />July ------------ >September <br />(FF 71 - October --------- >December <br />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 />