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NVENTORY RECONCILIATION <br /> Q� tTERLY SUMMARY REPORT FORM <br /> J rr <br /> Facility Name: --Y ) t... 1 �.1r' oduct <br /> _ <br /> Facility Address: ` �.�rZ�l� i �1..�e,�C. _".. t <br /> Telephone: <br /> Person Fi�ng <br /> Report: Q r t:19 W-A-u- <br /> El <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 1, amount for all variations and the reason <br /> for exceeding the allowable limits. <br /> Date Tank I Amount Reason <br /> 1. 1, <br /> 2-,R�9/ 4061&d <br /> 2. <br /> 3 � ' <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 2 - April ----------->June <br /> Quartq - July ------------>September <br /> Quarter 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 /> (209) 468-3420 <br /> EH 23 019 (10/89) <br />