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� NVENTORY. RECONCILIATION <br /> Q,, ATERLY SUMMARY REPORT FORT, <br />� FacilitY Name: <br /> � Tank # §ize Product <br /> � . <br /> Facility Address: 1 �•�� � c� <br /> Telephone: <br /> Person Filin��� �p <br /> eport• �X rC c� l ' <br /> � •J4 cn <br /> �� W LL, I hereby certify under penalty of perjury that all inventory <br /> variations for the above mentioned facility were within the <br /> �; <br /> allowable limits for this quarter. (No in column 13 of the <br /> tu-) Inventory Reconciliation Sheet. ) <br /> 71L3 Q w Inventory variations exceeded the allowable limits for this <br /> s 5a- quarter. I hereby certify under penalty of perjury that the <br /> source for the variation was not due to authorized (leak) <br /> releape. (Yes in Column 13 of the Inventory Reconciliation <br /> Sheet)-. <br /> List date, tank 1, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Date Tank Amount Reason <br /> 1.. - <br /> 3. -C <br /> 4. - �� �j C� to <br /> J3 CES { <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 ----------->June <br /> oQiarter ,- July ------------>September <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 />