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'.0 "% <br />14 <br />Facility Name: <br />INVENTORY.RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />Facility Address: C:�)I�N \1v%tzu� <br />Telephone: ZZL L <br />Person Filing - <br />Report: _ U\(�JUZ Q/1. <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 />Tank <br />v\ L_ <br />Amount <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 Jnuary-->March <br />uar er <br />2 - April ----------- >June <br />RECEIVE Low. <br />Quarter <br />3 - July ------------>September <br />Quarter <br />4 - October --------->December <br />JUL 2 6 T91 <br />HEALTH <br />L H <br />ENVIRONM�.NTAPERMIT/�t�2LH_ <br />Send to: SAN <br />JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 <br />E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />