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M <br />INVENTORY RECONCILIATION <br />QUARTERLY SUMMARY REPORT FORM <br />J <br />Facility Name•'�'"� <br />an Size Size ,Product <br />Facility Address: S ` �•�r0.r�� (� , <br />n a a <br />Telephone: <br />Person Filing <br />Report: hZ � L, <br />9 <br />(� I hereby certify under penalty of perjury that all inventory <br />L...� 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.off-'Y�1ND <br />5. \"a4\0 -C) 0 <br />Tank <br />Q <br />Amount <br />Reason <br />-S 1 on c <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 1 - January ---------- >March <br />Quarter 2 - April ----------- <br />>June <br />ruart <br />to - July ------------>September <br />er 4 - October --------->December <br />Send to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. Box 2009 <br />Stockton, CA 95201 <br />EH 23 019(209) 468-3420 <br />(10/89) <br />