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E <br />11 <br />Facility Name: <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORK <br />c <br />Facility Address: WL -1 9MVUP'_c <br />Telephone:�� <br />Person Filing <br />Report: - '__ _. k: - �C <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 Tank Amount Reason <br />2. <br />M <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 />Quarter <br />1 <br />- January ---------- >March <br />Quarter <br />2 <br />April <br />E C E <br />IV E [A) <br />uarter <br />3 <br />_ -__________->Sept <br />July ->September <br />Quarter <br />4 <br />- October --------->December <br />J U L 2 6 1991 <br />Send to: SAN <br />JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH <br />ENVIRONMENTAL HEALTH DIVISION <br />PEF\Wi11 /StRUiC,�S <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />