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INVENTORY.RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Name: Tank size Product <br />c�' �-Qj'r <br />Facility Address: <br />Telephone: '3` `f <br />Person Filing <br />Report: <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. (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 #, amount for all variations and the reason <br />for exceeding the allowable limits. <br />Date <br />1. <br />2. <br />3,_ <br />4. <br />5. <br />Tank k <br />AM-OUnt Reason <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 />-N <br />The quarterly summary report shall be'submitted with -in fifteen(I5)days of <br />the end of each quarter. Circle appropriate quarter. 4% <br />Quarter 1 - January ---------- >March <br />Quarter 2 - April ----------- >June <br />,-QMAKter July ------------ >September N", <br />,Quarter 4-)- October --------- >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 />