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NVENTORY, RECONCILIATION <br /> Qt . TERLY S RY REPORT FORM, <br /> FacilityName ! <br /> : Size Product <br /> C <br /> Facility Address: LZ G L'6e_ <br /> ►'r� 2-`U-3-7 G- fti1 iZ/YY� <br /> Telephone: <br /> Person Filing <br /> Report: �_�c N <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 /> =v Inventory variations exceeded the allowable limits for this <br /> �w quarter. I hereby certify under penalty of perjury that the <br /> r, Rl source for the variation was not due to authorized (leak) <br /> z t=releape. (Yes in Column 13 of the Inventory Reconciliation <br /> UiSheet) . <br /> >a <br /> w List date, tank 1, amount for all variations and the reason <br /> .for exceeding the allowable limits. <br /> Date Tank I Amount Reason <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 /> Quarter 1 - January---------->March <br /> Quarter_y- April ----------->June <br /> darter 3 l July ------------>September <br /> Quar er 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 />